Provider Demographics
NPI:1316914625
Name:CANTU, ROBERT CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CLARK
Last Name:CANTU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 OLD ROAD TO 9 ACRE COR
Mailing Address - Street 2:JOHN CUMING BUILDING, SUITE 820
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4181
Mailing Address - Country:US
Mailing Address - Phone:978-369-1386
Mailing Address - Fax:978-287-0047
Practice Address - Street 1:131 OLD ROAD TO 9 ACRE COR
Practice Address - Street 2:JOHN CUMING BUILDING, SUITE 820
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4181
Practice Address - Country:US
Practice Address - Phone:978-369-1386
Practice Address - Fax:978-287-0047
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA28386174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB73441Medicare UPIN
MAM10876Medicare ID - Type Unspecified