Healthcare Provider Details

I. General information

NPI: 1609858844
Provider Name (Legal Business Name): JOHN W KAVANAUGH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 HEALTH PKWY SUITE E
PAW PAW MI
49079-8242
US

IV. Provider business mailing address

451 HEALTH PKWY SUITE E
PAW PAW MI
49079-8242
US

V. Phone/Fax

Practice location:
  • Phone: 269-655-3090
  • Fax: 269-655-0763
Mailing address:
  • Phone: 269-655-3090
  • Fax: 269-655-0763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301405215
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: