Healthcare Provider Details

I. General information

NPI: 1760500011
Provider Name (Legal Business Name): MICHAEL FREDRIC CANTWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CALIFORNIA ST SUITE #103
SAN FRANCISCO CA
94115-2753
US

IV. Provider business mailing address

2951 SHASTA RD
BERKELEY CA
94708-2117
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-3503
  • Fax: 415-600-1327
Mailing address:
  • Phone: 415-600-3503
  • Fax: 415-600-1327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG060393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: