Provider Demographics
NPI:1841871241
Name:KAVANAUGH, COLIN DAVID (MD)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:DAVID
Last Name:KAVANAUGH
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 1:1121 BELLWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9433
Mailing Address - Country:US
Mailing Address - Phone:608-424-3384
Mailing Address - Fax:608-424-6353
Practice Address - Street 1:1121 BELLWEST BLVD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9433
Practice Address - Country:US
Practice Address - Phone:608-424-3384
Practice Address - Fax:608-424-6353
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77586207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine