Provider Demographics
NPI:1205857505
Name:CANTRELL, PATRICIA R (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:R
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE STATE ROUTE 291
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2939
Mailing Address - Country:US
Mailing Address - Phone:816-246-7779
Mailing Address - Fax:816-246-7780
Practice Address - Street 1:215 SE STATE ROUTE 291
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-2939
Practice Address - Country:US
Practice Address - Phone:816-246-7779
Practice Address - Fax:816-246-7780
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO2002031833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO33865026OtherBCBS
TNU75825Medicare UPIN
MOW43E736Medicare PIN