Provider Demographics
NPI:1275941924
Name:CANONIGO, RONALDO (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RONALDO
Middle Name:
Last Name:CANONIGO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19528 VENTURA BLVD # 478
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2917
Mailing Address - Country:US
Mailing Address - Phone:818-261-4995
Mailing Address - Fax:818-337-7503
Practice Address - Street 1:19528 VENTURA BLVD # 478
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2917
Practice Address - Country:US
Practice Address - Phone:818-261-4995
Practice Address - Fax:818-337-7503
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB218546Medicare PIN