Provider Demographics
NPI:1265454680
Name:CANOVA, GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:CANOVA
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 1:2993 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5977
Mailing Address - Country:US
Mailing Address - Phone:208-378-0400
Mailing Address - Fax:208-378-7529
Practice Address - Street 1:2993 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5977
Practice Address - Country:US
Practice Address - Phone:208-378-0400
Practice Address - Fax:208-378-7529
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD93715Medicare UPIN