Provider Demographics
NPI:1407054976
Name:CANTILLO, MANUEL EDWARDO (DO)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:EDWARDO
Last Name:CANTILLO
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5012 BOULDER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-6074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3916 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2383
Practice Address - Country:US
Practice Address - Phone:919-956-9300
Practice Address - Fax:919-287-1600
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02990207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1407054976Medicaid
AZ232625Medicaid