Provider Demographics
NPI:1356866354
Name:PAN AMERICAN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PAN AMERICAN MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:CANTU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-900-9284
Mailing Address - Street 1:2496 GRAND CENTRAL PKWY APT 3
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-5055
Mailing Address - Country:US
Mailing Address - Phone:956-832-2053
Mailing Address - Fax:407-900-7984
Practice Address - Street 1:8421 S ORANGE BLOSSOM TRL STE 124
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-8243
Practice Address - Country:US
Practice Address - Phone:407-900-9284
Practice Address - Fax:407-900-7984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty