Healthcare Provider Details

I. General information

NPI: 1053475061
Provider Name (Legal Business Name): IVAN T KANNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74785 HIGHWAY 111 SUITE 100
INDIAN WELLS CA
92210
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4443
  • Fax: 330-493-8677
Mailing address:
  • Phone: 330-493-4443
  • Fax: 330-493-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG40555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: