1760595516 NPI number — BRIAN F CANAVAN DO

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760595516 NPI number — BRIAN F CANAVAN DO

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CANAVAN

Provider First Name:

BRIAN

Provider Middle Name:

F

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DO

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:

1760595516

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/20/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

629 CRANBURY RD FL 2

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

EAST BRUNSWICK

Provider Business Mailing Address State Name:

NJ

Provider Business Mailing Address Postal Code:

08816-4096

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

732-390-7750

Provider Business Mailing Address Fax Number:

732-390-7725

Provider First Line Business Practice Location Address:

34-36 PROGRESS STREET

Provider Second Line Business Practice Location Address:

SUITE B2

Provider Business Practice Location Address City Name:

EDISON

Provider Business Practice Location Address State Name:

NJ

Provider Business Practice Location Address Postal Code:

08820

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

908-757-9696

Provider Business Practice Location Address Fax Number:

908-757-9721

Provider Enumeration Date:

08/16/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RH0003X , with the licence number:  25MB05551400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: F03506 . This is a "ACS" identifier . This identifiers is of the category "OTHER".
• Identifier: 110108158 . This is a "UNITED HEALTHCARE MEDI" identifier . This identifiers is of the category "OTHER".
• Identifier: P788711 . This is a "OXFORD HEALTHCARE MEDI" identifier . This identifiers is of the category "OTHER".
• Identifier: 223254679001 . This is a "QUALCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 1790396281 . This is a "TITAN HEALTH GROUP NPI#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: J021315 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
• Identifier: P788711 . This is a "OXFORD HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
• Identifier: F03506 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".
• Identifier: 0469749 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 0469749 . This is a "US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 223254679 . This is a "BLUE SHIELD HORIZON" identifier . This identifiers is of the category "OTHER".
• Identifier: 1790396281 . This is a "TITAN HEALTH NPI GROUP #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
• Identifier: 6556906 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".