Provider Demographics
NPI:1144749714
Name:CANTOR, EDISSON
Entity Type:Individual
Prefix:
First Name:EDISSON
Middle Name:
Last Name:CANTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 W LEROY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1128
Mailing Address - Country:US
Mailing Address - Phone:813-545-7931
Mailing Address - Fax:
Practice Address - Street 1:1 LELY HIGH SCHOOL BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-7823
Practice Address - Country:US
Practice Address - Phone:239-377-1937
Practice Address - Fax:239-377-2190
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL26032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22OtherRESPIRATORY, REHABILITATIVE & RESTORATIVE SERVICE PROVIDERS