Healthcare Provider Details

I. General information

NPI: 1457336893
Provider Name (Legal Business Name): LARRY KEITH CANTLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 HIGHLAND OAKS DR SUITE 201
WINSTON SALEM NC
27103-7106
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-0020
  • Fax: 336-765-0581
Mailing address:
  • Phone: 336-765-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number24230
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: