Healthcare Provider Details

I. General information

NPI: 1336111210
Provider Name (Legal Business Name): LAMONT EDWARD CAVANAGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S SAINT LOUIS AVE
TULSA OK
74120-5440
US

IV. Provider business mailing address

PO BOX 268838
OKLAHOMA CITY OK
73126-8838
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4400
  • Fax: 918-619-4639
Mailing address:
  • Phone: 918-619-4400
  • Fax: 918-619-4639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number18457
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18457
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: