Provider Demographics
NPI:1275113094
Name:CANESTRARI, MATTHEW PATRICK
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PATRICK
Last Name:CANESTRARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MONTICELLO AVE # 210
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3442
Mailing Address - Country:US
Mailing Address - Phone:817-529-8514
Mailing Address - Fax:469-453-5075
Practice Address - Street 1:3100 MONTICELLO AVE # 210
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3442
Practice Address - Country:US
Practice Address - Phone:817-529-8514
Practice Address - Fax:469-453-5075
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
999999999OtherNOT APPLICABLE