Basic Information
| Provider Information | |||||||||
| NPI: | 1144286782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTU | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14601 45TH AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113552200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186703135 | ||||||||
| FaxNumber: | 7186704449 | ||||||||
| Practice Location | |||||||||
| Address1: | 146-01 45 AVENUE | ||||||||
| Address2: | ROOM 211 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186705775 | ||||||||
| FaxNumber: | 7183216141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 06/22/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 169342 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01046551 | 05 | NY | MEDICAID |