Healthcare Provider Details

I. General information

NPI: 1124076856
Provider Name (Legal Business Name): BARRY L KAVANAUGH JR. OD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 SEVEN LAKES DR
WEST END NC
27376-9756
US

IV. Provider business mailing address

PO BOX 839
WEST END NC
27376-0839
US

V. Phone/Fax

Practice location:
  • Phone: 910-673-3937
  • Fax: 910-673-3266
Mailing address:
  • Phone: 910-673-3937
  • Fax: 910-673-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1295
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: