Provider Demographics
NPI:1013553957
Name:VALDEBRAN CANALES, MANUEL AUGUSTO
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:AUGUSTO
Last Name:VALDEBRAN CANALES
Suffix:
Gender:M
Credentials:
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 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:5500 FRONT ST STE 440
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8137
Practice Address - Country:US
Practice Address - Phone:843-985-3565
Practice Address - Fax:843-985-9389
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4383413207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology