Provider Demographics
NPI:1063547792
Name:CANTOR, JERROLD DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:DAVID
Last Name:CANTOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2621 S BRISTOL ST STE 305
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-5719
Mailing Address - Country:US
Mailing Address - Phone:714-751-0034
Mailing Address - Fax:714-751-1132
Practice Address - Street 1:2621 S BRISTOL ST STE 305
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5719
Practice Address - Country:US
Practice Address - Phone:714-751-0034
Practice Address - Fax:714-751-1132
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG23528207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G235280Medicaid
CA00G235280Medicaid
CAWG23528AMedicare ID - Type Unspecified
CAWG23528BMedicare ID - Type Unspecified
CAA41982Medicare UPIN