Provider Demographics
NPI:1770551640
Name:CANONICO, DOMENIC MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:DOMENIC
Middle Name:MICHAEL
Last Name:CANONICO
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 1:507 NW ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3504
Mailing Address - Country:US
Mailing Address - Phone:931-393-4332
Mailing Address - Fax:931-393-2304
Practice Address - Street 1:507 NW ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3504
Practice Address - Country:US
Practice Address - Phone:931-393-4332
Practice Address - Fax:931-393-2304
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18819207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0192943OtherBCBS
TN040013804OtherRAILROAD MEDICARE
TN3085592Medicaid
TN3085593Medicare PIN
TN0192943OtherBCBS