Provider Demographics
NPI:1174656102
Name:CANON, FERNANDO BASCO (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:BASCO
Last Name:CANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8337 TELEGRAPH RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4909
Mailing Address - Country:US
Mailing Address - Phone:562-806-1321
Mailing Address - Fax:562-806-0801
Practice Address - Street 1:8337 TELEGRAPH RD
Practice Address - Street 2:SUITE 210
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4909
Practice Address - Country:US
Practice Address - Phone:562-806-1321
Practice Address - Fax:562-806-0801
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30070207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA30070AMedicare ID - Type Unspecified
CAA25957Medicare UPIN