Basic Information
Provider Information | |||||||||
NPI: | 1891701173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAVANAGH | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | T. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26726 | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787550726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124078686 | ||||||||
FaxNumber: | 5124214489 | ||||||||
Practice Location | |||||||||
Address1: | 15803 WINDERMERE DR #103 | ||||||||
Address2: |   | ||||||||
City: | PFLUGERVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 786602482 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5129892680 | ||||||||
FaxNumber: | 5129890953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 05/18/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M1043 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 172772901 | 05 | TX |   | MEDICAID | 172772903 | 05 | TX |   | MEDICAID | 172772904 | 05 | TX |   | MEDICAID | 172772902 | 05 | TX |   | MEDICAID |