Provider Demographics
NPI:1487966313
Name:KAVANAUGH, AUBREY A (MD)
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:A
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 1:8800 SE 15
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-8001
Mailing Address - Country:US
Mailing Address - Phone:405-739-6840
Mailing Address - Fax:405-455-3087
Practice Address - Street 1:8800 SE 15
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-8001
Practice Address - Country:US
Practice Address - Phone:405-739-6840
Practice Address - Fax:405-455-3087
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK27836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1487966313Medicare NSC