Healthcare Provider Details

I. General information

NPI: 1003979063
Provider Name (Legal Business Name): JEFF LAWRENCE KANTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SUNNYBROOK RD
RALEIGH NC
27610-1855
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006026942
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number2018-01805
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: