Healthcare Provider Details

I. General information

NPI: 1174103287
Provider Name (Legal Business Name): MICHAEL CANNADY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 VISTA WAY
OCEANSIDE CA
92056-4568
US

IV. Provider business mailing address

6070 AVENIDA ENCINAS STE 100
CARLSBAD CA
92011-1001
US

V. Phone/Fax

Practice location:
  • Phone: 760-729-7298
  • Fax:
Mailing address:
  • Phone: 760-444-0102
  • Fax: 760-688-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number299375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: