Provider Demographics
NPI:1972627875
Name:CANTRELL, MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6857 GANGLE CT
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3074
Mailing Address - Country:US
Mailing Address - Phone:678-526-7985
Mailing Address - Fax:678-526-7985
Practice Address - Street 1:6857 GANGLE CT
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3074
Practice Address - Country:US
Practice Address - Phone:678-526-7985
Practice Address - Fax:678-526-7985
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005948213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVO5152Medicare UPIN