Healthcare Provider Details

I. General information

NPI: 1083996169
Provider Name (Legal Business Name): ALAN MICHAEL CANTRELL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 819 BOX 18
FPO AE
09645-0001
US

IV. Provider business mailing address

PSC 819 BOX 18
FPO AE
09645-0001
US

V. Phone/Fax

Practice location:
  • Phone: 195-682-3495
  • Fax:
Mailing address:
  • Phone: 195-682-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002060
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: