Basic Information
| Provider Information | |||||||||
| NPI: | 1639517808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTILLEP | ||||||||
| FirstName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 EXECUTIVE SQ STE 450 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920378411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588100000 | ||||||||
| FaxNumber: | 8582681911 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 WARNER AVE STE 218 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146419696 | ||||||||
| FaxNumber: | 7146411211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2013 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A125649 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | A125649 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | A125649 | 01 | CA | LICENCE NUMBER | OTHER |