Healthcare Provider Details

I. General information

NPI: 1598155830
Provider Name (Legal Business Name): MONICA EDITH CANTU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 LPGA BLVD STE 130 PRIMECARE AT TWIN LAKES
DAYTONA BEACH FL
32117-7131
US

IV. Provider business mailing address

1890 LPGA BLVD STE 130 PRIMECARE AT TWIN LAKES
DAYTONA BEACH FL
32117-7131
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-2212
  • Fax: 386-274-1508
Mailing address:
  • Phone: 386-274-2212
  • Fax: 386-274-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME122370
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: