Provider Demographics
NPI:1487897922
Name:KAVANAUGH, MINDIE MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:MINDIE
Middle Name:MICHELLE
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-5915
Mailing Address - Fax:318-675-5948
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-1431
Practice Address - Fax:318-813-1444
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203912207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA39108YH54OtherMEDICARE - PTAN
LA19933147Medicaid