Healthcare Provider Details

I. General information

NPI: 1265461412
Provider Name (Legal Business Name): LISA A. CAVANAUGH, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 GLENWOOD RD
GLEN HEAD NY
11545-1221
US

IV. Provider business mailing address

77 GLENWOOD RD
GLEN HEAD NY
11545-1221
US

V. Phone/Fax

Practice location:
  • Phone: 516-759-1131
  • Fax: 516-676-5727
Mailing address:
  • Phone: 516-759-1131
  • Fax: 516-676-5727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201939-1
License Number StateNY

VIII. Authorized Official

Name: DR. LISA ANNE CAVANAUGH
Title or Position: CEO / MEDICIAL DIRECTOR
Credential: M.D., F.A.A.P.
Phone: 516-759-1131