Provider Demographics
NPI:1093716920
Name:KANTROW, MARK LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEWIS
Last Name:KANTROW
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:7777 HENNESSY BLVD STE 503
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4366
Practice Address - Country:US
Practice Address - Phone:225-765-2273
Practice Address - Fax:225-374-0251
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09411R207RH0002X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1962783Medicaid
LAP00020218OtherRAIL ROAD MEDICARE
MS00621757Medicaid
MS00621757Medicaid
LAF81160Medicare UPIN