Provider Demographics
NPI:1912996984
Name:CANIZALES, JUAN R (OD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:R
Last Name:CANIZALES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BILLINGSLEY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5020
Mailing Address - Country:US
Mailing Address - Phone:704-366-0223
Mailing Address - Fax:704-366-5327
Practice Address - Street 1:12731 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3632
Practice Address - Country:US
Practice Address - Phone:239-418-0999
Practice Address - Fax:239-274-0773
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4007152W00000X
NC2129152W00000X
HI740152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00369116OtherRAIL ROAD MEDICARE
FLP00369116OtherRAIL ROAD MEDICARE