Provider Demographics
NPI:1750379806
Name:CAVAN, CLODOVEO (MD)
Entity type:Individual
Prefix:DR
First Name:CLODOVEO
Middle Name:
Last Name:CAVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROUTE 73 NORTH 40 LAKE CENTER DRIVE
Mailing Address - Street 2:SUITE 201A
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3425
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0346
Practice Address - Street 1:175 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-2038
Practice Address - Country:US
Practice Address - Phone:609-914-6180
Practice Address - Fax:609-914-6182
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04243000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3947301Medicaid
NJ3947301Medicaid
NJC57036Medicare UPIN