Provider Demographics
NPI:1700874179
Name:CANAKIS, JERROLD S (MD)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:S
Last Name:CANAKIS
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 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-546-6400
Mailing Address - Fax:
Practice Address - Street 1:10344 OLD OCN BLVD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-641-2938
Practice Address - Fax:410-641-4904
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10006596207RG0100X
MDD0059594207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400997500Medicaid
MDF78825Medicare UPIN
MD511M785FMedicare ID - Type Unspecified
DEG01509J01Medicare PIN