Provider Demographics
NPI:1730676362
Name:KANITRA, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:KANITRA
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 1:3500 GASTON AVE
Mailing Address - Street 2:3 Y-WING, L3.2004
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2088
Mailing Address - Country:US
Mailing Address - Phone:469-814-3518
Mailing Address - Fax:469-814-4854
Practice Address - Street 1:3500 GASTON AVE STE 1013
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2088
Practice Address - Country:US
Practice Address - Phone:469-814-3518
Practice Address - Fax:469-814-4854
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301504105208600000X
TXBP100840992086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery