Provider Demographics
NPI:1356355366
Name:KAVANAGH, ELISA M (DPM)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:M
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MAMARONECK AVE STE 502
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2433
Mailing Address - Country:US
Mailing Address - Phone:914-472-1000
Mailing Address - Fax:914-472-1008
Practice Address - Street 1:440 MAMARONECK AVE STE 502
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-2433
Practice Address - Country:US
Practice Address - Phone:914-472-1000
Practice Address - Fax:914-472-1008
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005920213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P2738692OtherOXFORD
2404394OtherUNITED
6298866OtherGHI PPO
000000082282OtherGHI HMO
PH7951OtherBCBS
NY1582677OtherCIGNA
160452POtherHIP
NY3C6175OtherHEALTHNET
6298866OtherGHI PPO
160452POtherHIP