Provider Demographics
NPI:1295353670
Name:CANTOR, LUIS
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:
Last Name:CANTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3540
Mailing Address - Country:US
Mailing Address - Phone:321-726-6331
Mailing Address - Fax:
Practice Address - Street 1:1541 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3540
Practice Address - Country:US
Practice Address - Phone:321-726-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-11
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113587363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty