Basic Information
| Provider Information | |||||||||
| NPI: | 1962573626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 KUENZLI ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895020845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825262 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1835 ODDIE BLVD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894313559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825140 | ||||||||
| FaxNumber: | 7759825141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-082935 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 15475 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 833230 | 01 | MEDICARE GROUP # FOR PONTIAC | OTHER | 036082935 | 05 | IL | MEDICAID |