Provider Demographics
NPI:1659416956
Name:LACANILAO, ANGELITO BUENCAMINO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELITO
Middle Name:BUENCAMINO
Last Name:LACANILAO
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 1:340 CHARLIE SMITH SR HWY
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3101
Mailing Address - Country:US
Mailing Address - Phone:912-882-5030
Mailing Address - Fax:888-476-5235
Practice Address - Street 1:340 CHARLIE SMITH SR HWY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3101
Practice Address - Country:US
Practice Address - Phone:912-882-5030
Practice Address - Fax:888-476-5235
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA083558714BMedicaid
GA08BBQQDMedicare ID - Type Unspecified
GAH84791Medicare UPIN