Provider Demographics
NPI:1932147055
Name:CANTRELL, MIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 NIMITZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-3566
Mailing Address - Country:US
Mailing Address - Phone:424-832-8268
Mailing Address - Fax:424-832-8270
Practice Address - Street 1:11500 NIMITZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3566
Practice Address - Country:US
Practice Address - Phone:424-832-8268
Practice Address - Fax:424-832-8270
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39040207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39040OtherLICENCE