Provider Demographics
NPI:1013008135
Name:KANELLOS, ANGELO W (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:W
Last Name:KANELLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5560 KIETZKE LN
Mailing Address - Street 2:BLDG A
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3019
Mailing Address - Country:US
Mailing Address - Phone:775-322-7811
Mailing Address - Fax:
Practice Address - Street 1:10745 DOUBLE R BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-8979
Practice Address - Country:US
Practice Address - Phone:775-850-6500
Practice Address - Fax:775-850-6501
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6421208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0020-16386Medicaid
NVF28967Medicare UPIN
NV34WCHJR03Medicare ID - Type Unspecified