Provider Demographics
NPI:1417996117
Name:CANTRELL, CAROL R (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:R
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-3929
Mailing Address - Country:US
Mailing Address - Phone:615-384-8133
Mailing Address - Fax:615-384-8199
Practice Address - Street 1:2304 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-3929
Practice Address - Country:US
Practice Address - Phone:615-384-8133
Practice Address - Fax:615-384-8199
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD018063174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3037764Medicaid
TN3136613OtherBLUECROSS BLUESHIELD
TNB00096Medicare UPIN
TN3136613OtherBLUECROSS BLUESHIELD