Provider Demographics
NPI:1073677555
Name:CANILLAS, ELMO (MD)
Entity Type:Individual
Prefix:DR
First Name:ELMO
Middle Name:
Last Name:CANILLAS
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 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-295-9725
Practice Address - Street 1:55 MEADOWLANDS PARKWAY
Practice Address - Street 2:
Practice Address - City:SECAUCAS
Practice Address - State:NJ
Practice Address - Zip Code:07094
Practice Address - Country:US
Practice Address - Phone:201-819-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05712700174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5102502Medicaid
NJP01281145OtherRAILROAD MEDICARE
NJ5102502Medicaid