Provider Demographics
NPI:1457336893
Name:CANTLEY, LARRY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KEITH
Last Name:CANTLEY
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-765-0020
Mailing Address - Fax:
Practice Address - Street 1:755 HIGHLAND OAKS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7106
Practice Address - Country:US
Practice Address - Phone:336-765-0020
Practice Address - Fax:336-765-0581
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24230207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89127FNMedicaid
SCQ24230Medicaid
NC127FNOtherBLUE CROSS
NC1001OtherPARTNERS
WV3002077000Medicaid
NCA0333OtherMEDCOST
NC4098171OtherAETNA
VA5850215Medicaid
NC127FNOtherBLUE CROSS
NC205268CMedicare PIN
NC205268BMedicare PIN
NC4098171OtherAETNA