Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | ED0456A | WV |
N | 207U00000X | Nuclear Medicine Specialist | 125.066294 | IL |
Y | 208D00000X | General Practice Physician | 032.0133827 | VT |
NPI | 1164837605 |
---|---|
Provider Name | Ernesto Cantu JR. |
First Address | Essex Junction, VT 05452-3816 |
Second Address | Saint Albans, VT 05478-9753 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2014 |
Last Update Date | 30/06/2020 |