Provider Demographics
NPI:1871627315
Name:DR. DAVID C. CAVALLARO, D.P.M., INC.
Entity type:Organization
Organization Name:DR. DAVID C. CAVALLARO, D.P.M., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:CAVALLARO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-631-2333
Mailing Address - Street 1:7370 S WALKER AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-7628
Mailing Address - Country:US
Mailing Address - Phone:405-631-2333
Mailing Address - Fax:405-631-2350
Practice Address - Street 1:7370 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-7628
Practice Address - Country:US
Practice Address - Phone:405-631-2333
Practice Address - Fax:405-631-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-10-25
Deactivation Date:2008-08-11
Deactivation Code:
Reactivation Date:2011-02-02
Provider Licenses
StateLicense IDTaxonomies
OK140213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1548261050OtherINDIVIDUAL NPI #
OK100779410AMedicaid
OK078425699002OtherBCBS PROVIDER #
OK078425699002OtherBCBS PROVIDER #
OK1003890001Medicare NSC
OK1548261050OtherINDIVIDUAL NPI #
OK078425699Medicare PIN