Provider Demographics
NPI:1699955617
Name:AMMALA CANTRELL
Entity type:Organization
Organization Name:AMMALA CANTRELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-673-5553
Mailing Address - Street 1:PO BOX 50670
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32240-0670
Mailing Address - Country:US
Mailing Address - Phone:904-372-0208
Mailing Address - Fax:904-853-6559
Practice Address - Street 1:1370 13TH AVE S
Practice Address - Street 2:SUITE 216A
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3230
Practice Address - Country:US
Practice Address - Phone:904-372-0208
Practice Address - Fax:904-853-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8204OtherBC/BS OF FLORIDA
FLK8204Medicare PIN