Provider Demographics
NPI:1518969260
Name:CANALES, LUIS IVAN (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:IVAN
Last Name:CANALES
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:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-0217
Mailing Address - Country:US
Mailing Address - Phone:315-769-1667
Mailing Address - Fax:315-769-6430
Practice Address - Street 1:181 MAPLE STREET
Practice Address - Street 2:SUITE C
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662
Practice Address - Country:US
Practice Address - Phone:315-769-1667
Practice Address - Fax:315-769-6430
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208001207RA0000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01794976Medicaid
NY56848BMedicare ID - Type Unspecified
NY01794976Medicaid