Provider Demographics
NPI:1699754150
Name:CANTRELL, ELROY (DO)
Entity type:Individual
Prefix:DR
First Name:ELROY
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13205 BOOKER T WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:HARDY
Mailing Address - State:VA
Mailing Address - Zip Code:24101-3947
Mailing Address - Country:US
Mailing Address - Phone:540-719-1815
Mailing Address - Fax:540-719-2867
Practice Address - Street 1:13205 BOOKER T WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3947
Practice Address - Country:US
Practice Address - Phone:540-719-1815
Practice Address - Fax:540-721-3623
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8034207P00000X, 207Q00000X
VA0102-201940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699754150Medicaid
VA1699754150Medicaid
015021C51Medicare PIN
015031C47Medicare PIN
TXA65628Medicare UPIN