1104970417 NPI number — DR. PATRICK DESMOND KAVANAGH M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104970417 NPI number — DR. PATRICK DESMOND KAVANAGH M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

KAVANAGH

Provider First Name:

PATRICK

Provider Middle Name:

DESMOND

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1104970417

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/11/2025

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

10000 BO BAJURAS

Provider Second Line Business Mailing Address:

VILLA MONTANA UNIT B3

Provider Business Mailing Address City Name:

ISABELA

Provider Business Mailing Address State Name:

PR

Provider Business Mailing Address Postal Code:

00662

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

305-354-0458

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1430 S DIXIE HWY STE 304

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CORAL GABLES

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33146-3159

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

888-696-4322

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

01/23/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  0101264898 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: 25MA09668800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207R00000X , with the licence number: ME96603 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: MD-20583 . This is a "HAWAII STATE LICENSE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
• Identifier: MD462196 . This is a "PENNSYLVANIA STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 078512 . This is a "GEORGIA STATE LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
• Identifier: 2019-01534 . This is a "NORTH CAROLINA STATE LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 76171 . This is a "MONTANA STATE LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
• Identifier: 0101264898 . This is a "VIRGINIA STATE LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 31765 . This is a "NEBRASKA STATE LICENSE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
• Identifier: 51762 . This is a "SOUTH CAROLINA LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 61402 . This is a "CONNECTICUT STATE LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
• Identifier: 036145182 . This is a "ILLINOIS STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
• Identifier: 10800188 . This is a "UTAT STATE LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: 57668 . This is a "TENNESSEE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: 7206220 . This is a "WISCONSON STATE LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
• Identifier: TL6006 . This is a "WYOMING STATE LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
• Identifier: MD.43069 . This is a "STATE LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 308192 . This is a "LOUISIANA STATE LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
• Identifier: 04-41271 . This is a "KANSAS STATE LICENSE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
• Identifier: 4301115326 . This is a "MICHIGAN STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: MD60947259 . This is a "WASHINGTON STATE LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: 022203 . This is a "PUERTO RICO STATE LICENSE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".