Healthcare Provider Details

I. General information

NPI: 1124757497
Provider Name (Legal Business Name): BENJAMIN JOSEPH CAVISTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # AF-1020
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

3201 NORRIS CT
AUGUSTA GA
30907-3737
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4467
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number13812
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: