=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053693580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN CARLOS CANTU M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2011
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7359 LAKE UNDERHILL RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-900-9284
-----------------------------------------------------
Fax | 407-203-8887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7359 LAKE UNDERHILL RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-900-9284
-----------------------------------------------------
Fax | 407-203-8887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 18320
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ACN673
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------