Provider Demographics
NPI:1265703474
Name:CAVANAUGH, JEFFREY DAVID (CCP)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DAVID
Last Name:CAVANAUGH
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
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Mailing Address - Street 1:15010 IRON HORSE WAY
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4593
Mailing Address - Country:US
Mailing Address - Phone:210-621-3572
Mailing Address - Fax:
Practice Address - Street 1:3463 MAGIC DR
Practice Address - Street 2:SUITE T21
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2973
Practice Address - Country:US
Practice Address - Phone:210-614-8101
Practice Address - Fax:210-614-8102
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPF1057242T00000X
CO166637246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant