Provider Demographics
NPI:1639148026
Name:JERROLD D CANTOR MD INC
Entity Type:Organization
Organization Name:JERROLD D CANTOR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERROLD
Authorized Official - Middle Name:D
Authorized Official - Last Name:CANTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-751-0034
Mailing Address - Street 1:2621 S BRISTOL ST
Mailing Address - Street 2:STE 305
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704
Mailing Address - Country:US
Mailing Address - Phone:714-751-0034
Mailing Address - Fax:714-751-1132
Practice Address - Street 1:2621 S BRISTOL ST
Practice Address - Street 2:STE 305
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:714-751-0034
Practice Address - Fax:714-751-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23528207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G235280Medicaid
CAW2996Medicare PIN
CAWG23528AMedicare ID - Type Unspecified
CAWG23528BMedicare ID - Type Unspecified
A41982Medicare UPIN
CA00G235280Medicaid