Healthcare Provider Details

I. General information

NPI: 1881674695
Provider Name (Legal Business Name): TERRENCE J CAVANAUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD
PHOENIX AZ
85013-4409
US

IV. Provider business mailing address

PO BOX 548
COTTONWOOD AZ
86326-0548
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3430
  • Fax:
Mailing address:
  • Phone: 928-634-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number29952
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: