Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 2006026942 | MO |
Y | 2080P0206X | Pediatric Gastroenterologist | 2018-01805 | NC |
NPI | 1003979063 |
---|---|
Provider Name | Jeff Lawrence Kantor |
First Address | Raleigh, NC 27604-0010 |
Second Address | Raleigh, NC 27610-1855 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 02/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
204028302 | (05) | MO |
774420 | HEALTHLINK (01) | MO |
I69952 | (02) | MO |