Provider Demographics
NPI:1033164918
Name:CANTWELL, VERNON WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:VERNON
Middle Name:WILLIAM
Last Name:CANTWELL
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:211 4TH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-397-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019173207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1365670Medicaid
LA4J051CQ57Medicare ID - Type Unspecified
LA1365670Medicaid