Provider Demographics
NPI:1336227792
Name:JERROLD CANTOR, MD, INC
Entity type:Organization
Organization Name:JERROLD CANTOR, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CANTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-751-0034
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23528207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW2996Medicare ID - Type Unspecified