Healthcare Provider Details

I. General information

NPI: 1467425124
Provider Name (Legal Business Name): DAVID M CANTRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 KENNESTONE HOSPITAL BLVD SUITE 201
MARIETTA GA
30060-1161
US

IV. Provider business mailing address

320 KENNESTONE HOSPITAL BLVD SUITE 201
MARIETTA GA
30060-1161
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-2457
  • Fax: 770-427-2706
Mailing address:
  • Phone: 770-427-2457
  • Fax: 770-427-2706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number032883
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: