Provider Demographics
NPI:1356323828
Name:KANTOR, JASON C (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:KANTOR
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 1:100 OCEANGATE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4312
Mailing Address - Country:US
Mailing Address - Phone:562-590-7400
Mailing Address - Fax:562-590-7452
Practice Address - Street 1:1300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3505
Practice Address - Country:US
Practice Address - Phone:310-832-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG402842085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G402840OtherBLUE SHIELD
CA00G402840Medicaid
CAWG40284LMedicare PIN
CA00G402842Medicare PIN
A48171Medicare UPIN
CAWG40284JMedicare PIN
CA00G402840Medicare PIN
CA00G402844Medicare PIN
CAWG40284HMedicare PIN
CA00G402841Medicare PIN
CA00G402840OtherBLUE SHIELD
CA00G402840Medicaid
CAWG40284KMedicare PIN
CABW451ZMedicare PIN