Healthcare Provider Details

I. General information

NPI: 1851395487
Provider Name (Legal Business Name): MARK S. CANTIERI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 PARK PL W STE 200
MISHAWAKA IN
46545-3513
US

IV. Provider business mailing address

12497 DRAGOON TRL
MISHAWAKA IN
46544-9449
US

V. Phone/Fax

Practice location:
  • Phone: 574-271-8646
  • Fax: 574-271-8624
Mailing address:
  • Phone: 574-633-4190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberIN2001185A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberIA01993
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: