Basic Information
| Provider Information | |||||||||
| NPI: | 1558351692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CABANTOG | ||||||||
| FirstName: | ALBERTO | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 308 S HARBOR CITY BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217330064 | ||||||||
| FaxNumber: | 3217337970 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 S HARBOR CITY BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217330064 | ||||||||
| FaxNumber: | 3217337970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | ME 96402 | FL | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | ME96042 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 202705274 | 01 | MA | UNITTED HEALTHCARE | OTHER | 202705274 | 01 | MA | GREAT WEST | OTHER | 97130902 | 01 | MA | NETWORK HEALTH | OTHER | 202705274004 | 01 | MA | TRICARE | OTHER | AA58878 | 01 | MA | HPHC | OTHER | 2036525 | 05 | MA | MEDICAID | 611000600 | 01 | MA | DOL | OTHER | 7245558 | 01 | MA | AETNA | OTHER |