Provider Demographics
NPI:1831260595
Name:CANNAVINO, CHRISTOPHER RAY (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RAY
Last Name:CANNAVINO
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 1:3020 CHILDRENS WAY # MC5003
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-309-6300
Mailing Address - Fax:
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-966-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA866362080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A866360Medicaid
CAI30697Medicare UPIN
CAWA86636AMedicare ID - Type Unspecified