Provider Demographics
NPI:1447364971
Name:CANTLIN, TERRY W (DO)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:W
Last Name:CANTLIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-2000
Mailing Address - Country:US
Mailing Address - Phone:802-234-9913
Mailing Address - Fax:802-728-2394
Practice Address - Street 1:44 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1381
Practice Address - Country:US
Practice Address - Phone:802-234-9913
Practice Address - Fax:802-728-2394
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0320000314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0006125Medicaid
VTVT6125Medicare ID - Type UnspecifiedMEDICARE
VTB57872Medicare UPIN