Provider Demographics
NPI:1407054976
Name:CANTILLO, MANUEL EDWARDO (DO)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:EDWARDO
Last Name:CANTILLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 MONTVALE GRANT WAY
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-1019
Mailing Address - Country:US
Mailing Address - Phone:602-403-0440
Mailing Address - Fax:
Practice Address - Street 1:9225 N 3RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2439
Practice Address - Country:US
Practice Address - Phone:602-445-0751
Practice Address - Fax:602-424-8128
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4693207R00000X
NC2021-02990207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ232625Medicaid