=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730140583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY J CAVACINI D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 07/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 216 SOUTHPARK CIR E
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-6108
-----------------------------------------------------
Fax | 904-823-9613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 SOUTHPARK CIR E
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-6108
-----------------------------------------------------
Fax | 904-823-9613
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | OS0007112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------