MEDICARE: DR. ETHAN ABRAHAM CANTY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	A185856	CA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	208000000X	Pediatrics Physician	185856	CA

General Provider Information

NPI Number	:	1790312536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHAN ABRAHAM CANTY MD

Provider Business Mailing Address
First Line	:	910 HALE PL STE 110
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91914-3598
Country	:	US
Telephone Number	:	619-704-7577
Fax Number	:	619-704-7578

Provider Business Practice Location Address
First Line	:	910 HALE PL STE 110
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91914-3598
Country	:	US
Telephone Number	:	619-704-7577
Fax Number	:	619-704-7578

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2020
Last Update Date	:	02/11/2026

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