Provider Demographics
NPI:1720197080
Name:KANTZLER, GARRICK B (MD)
Entity Type:Individual
Prefix:
First Name:GARRICK
Middle Name:B
Last Name:KANTZLER
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 1:805 37TH PL
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6564
Mailing Address - Country:US
Mailing Address - Phone:772-562-2330
Mailing Address - Fax:772-562-2592
Practice Address - Street 1:805 37TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6564
Practice Address - Country:US
Practice Address - Phone:772-562-2330
Practice Address - Fax:772-562-2592
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000122-0000169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD54209Medicare UPIN
FL31093Medicare ID - Type Unspecified