Provider Demographics
NPI:1962573626
Name:CANTY, MARK D (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:CANTY
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 1:780 KUENZLI ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-0845
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1835 ODDIE BLVD
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-3559
Practice Address - Country:US
Practice Address - Phone:775-982-5140
Practice Address - Fax:775-982-5141
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082935207Q00000X
NV15475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
833230OtherMEDICARE GROUP # FOR PONTIAC
IL036082935Medicaid
833230OtherMEDICARE GROUP # FOR PONTIAC
F25298Medicare UPIN
ILL66362Medicare ID - Type UnspecifiedINDIVIDUAL #
833230005Medicare PIN
IL080146923 - CA4079Medicare ID - Type UnspecifiedRR