Healthcare Provider Details

I. General information

NPI: 1164837605
Provider Name (Legal Business Name): ERNESTO CANTU JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CREST RD
SAINT ALBANS VT
05478-9753
US

IV. Provider business mailing address

14 WILDWOOD DR
ESSEX JUNCTION VT
05452-3816
US

V. Phone/Fax

Practice location:
  • Phone: 802-524-4554
  • Fax:
Mailing address:
  • Phone: 859-420-1849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberED0456A
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number125.066294
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number032.0133827
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: