1558351692 NPI number — DR. ALBERTO M CABANTOG M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558351692 NPI number — DR. ALBERTO M CABANTOG M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

CABANTOG

Provider First Name:

ALBERTO

Provider Middle Name:

M

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1558351692

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

11/03/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

308 S HARBOR CITY BLVD

Provider Second Line Business Mailing Address:

SUITE A

Provider Business Mailing Address City Name:

MELBOURNE

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

32901-1500

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

321-733-0064

Provider Business Mailing Address Fax Number:

321-733-7970

Provider First Line Business Practice Location Address:

240 W 11TH ST STE 103

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ERIE

Provider Business Practice Location Address State Name:

PA

Provider Business Practice Location Address Postal Code:

16501-1758

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

814-790-5111

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

10/27/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208VP0014X , with the licence number:  ME 96402 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0014X , with the licence number: MD458018 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 207L00000X , with the licence number: ME96042 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 202705274 . This is a "GREAT WEST" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: AA58878 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 202705274004 . This is a "TRICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 2036525 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 7245558 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 202705274 . This is a "UNITTED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 97130902 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: MD458018 . This is a "STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 611000600 . This is a "DOL" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".