Provider Demographics
NPI:1912968686
Name:CAVERLY, JEFFREY C (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
Last Name:CAVERLY
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 1:2200 NORTH MAYFAIR ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2252
Mailing Address - Country:US
Mailing Address - Phone:414-258-9511
Mailing Address - Fax:414-607-3946
Practice Address - Street 1:1509 WILSON TERRACE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG818062085R0202X
FLME1410682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G818060OtherBLUE SHIELD
CA1912968686OtherBLUE CROSS
CA1912968686Medicaid
P10145172OtherRR MEDICARE
CADZ481UMedicare PIN
CA1912968686Medicaid