Provider Demographics
NPI:1588617005
Name:CANELLOS, EVAN CHRIS (OD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:CHRIS
Last Name:CANELLOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 ROBBY LN
Mailing Address - Street 2:
Mailing Address - City:MANHASSET HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1105
Mailing Address - Country:US
Mailing Address - Phone:516-365-5012
Mailing Address - Fax:
Practice Address - Street 1:800 POLY PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7104
Practice Address - Country:US
Practice Address - Phone:718-836-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000002412152W00000X
NYVUT006229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG300044682Medicare PIN
NYA300001679Medicare PIN