Provider Demographics
NPI:1679565303
Name:KAVANAGH, COLIN (DO)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1936
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-1936
Mailing Address - Country:US
Mailing Address - Phone:515-471-9243
Mailing Address - Fax:515-471-9319
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1622
Practice Address - Fax:515-271-1411
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0219006Medicaid
IA080161522OtherRR MEDICARE
IAI0270Medicare ID - Type Unspecified
IA415300008Medicare PIN
IA0219006Medicaid