Provider Demographics
NPI:1770862047
Name:CANTU, SERGIO SAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:SAUL
Last Name:CANTU
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 1:779 N TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALICE
Mailing Address - State:TX
Mailing Address - Zip Code:78332-3883
Mailing Address - Country:US
Mailing Address - Phone:361-668-0919
Mailing Address - Fax:361-668-0816
Practice Address - Street 1:779 N TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-3883
Practice Address - Country:US
Practice Address - Phone:361-668-0919
Practice Address - Fax:361-668-0816
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0707208M00000X, 207Q00000X
TXP-0707208M00000X
NMMD2011-0550208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX300672801Medicaid