Provider Demographics
NPI:1851395487
Name:CANTIERI, MARK S (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:CANTIERI
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 1:12497 DRAGOON TRL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9449
Mailing Address - Country:US
Mailing Address - Phone:574-633-4190
Mailing Address - Fax:
Practice Address - Street 1:3555 PARK PL W
Practice Address - Street 2:STE 200
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3513
Practice Address - Country:US
Practice Address - Phone:574-271-8646
Practice Address - Fax:574-271-8624
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ2001185A204D00000X
IAIA01993204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200011350AMedicaid
INE23808Medicare UPIN
IN168320AMedicare ID - Type Unspecified