Provider Demographics
NPI:1932174596
Name:CANTU, JATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JATHAN
Middle Name:
Last Name:CANTU
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 1:300 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-5956
Mailing Address - Country:US
Mailing Address - Phone:903-655-6536
Mailing Address - Fax:903-655-4009
Practice Address - Street 1:300 WILSON ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5956
Practice Address - Country:US
Practice Address - Phone:903-655-6536
Practice Address - Fax:903-655-4009
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0193207Q00000X
TXG8036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U8524OtherBLUE CROSS
TX115747104Medicaid
NM34456341Medicaid
NM34456341Medicaid
TX8U8524OtherBLUE CROSS
NM341328409Medicare ID - Type Unspecified