Healthcare Provider Details

I. General information

NPI: 1407066384
Provider Name (Legal Business Name): JONATHON WADE CAVINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 N LEBANON ST STE 310
LEBANON IN
46052-8622
US

IV. Provider business mailing address

2705 N LEBANON ST STE 305
LEBANON IN
46052-8622
US

V. Phone/Fax

Practice location:
  • Phone: 765-485-8900
  • Fax: 765-485-8909
Mailing address:
  • Phone: 765-485-8852
  • Fax: 765-485-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01064975A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: