Provider Demographics
NPI:1790987568
Name:CARLOS R CANIZALES MD INC
Entity Type:Organization
Organization Name:CARLOS R CANIZALES MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANIZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-981-5923
Mailing Address - Street 1:305 N. 2ND AVENUE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-981-5923
Mailing Address - Fax:909-920-3054
Practice Address - Street 1:685 N 13TH AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4916
Practice Address - Country:US
Practice Address - Phone:909-981-5923
Practice Address - Fax:909-920-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A212830Medicaid
CA00A212830Medicaid
CA00A212830Medicaid