Provider Demographics
NPI:1265412506
Name:KANTOLA, RONALD L (DO)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:KANTOLA
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:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1768
Mailing Address - Country:US
Mailing Address - Phone:479-484-1010
Mailing Address - Fax:479-785-9916
Practice Address - Street 1:4200 JENNY LIND RD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-7660
Practice Address - Country:US
Practice Address - Phone:479-484-1010
Practice Address - Fax:479-785-9916
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-108668174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161909003Medicaid
AR161909003Medicaid
5N600Medicare PIN