Provider Demographics
NPI:1124095039
Name:CANTRELL, BETTY J (OD)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:J
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:218 W RUTLEDGE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:YATES CENTER
Practice Address - State:KS
Practice Address - Zip Code:66783-1240
Practice Address - Country:US
Practice Address - Phone:620-625-3311
Practice Address - Fax:620-625-2446
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS15243152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100321070AMedicaid
410040025OtherRAILROAD MEDICARE
410040025OtherRAILROAD MEDICARE
KS053913Medicare PIN