MEDICARE: MR. JOHN MARK CAVANAGH O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2236	MN

General Provider Information

NPI Number	:	1205921368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN MARK CAVANAGH O.D.

Provider Business Mailing Address
First Line	:	2655 INNSBRUCK DR
Second Line	:	SUITE B
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9303
Country	:	US
Telephone Number	:	651-636-2020
Fax Number	:	651-633-5036

Provider Business Practice Location Address
First Line	:	2655 INNSBRUCK DR
Second Line	:	SUITE B
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9303
Country	:	US
Telephone Number	:	651-636-2020
Fax Number	:	651-633-5036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	03/18/2009

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