Healthcare Provider Details

I. General information

NPI: 1689864522
Provider Name (Legal Business Name): SAMER KANAAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 RIVERWALK PKWY STE 120
RIVERSIDE CA
92505-3304
US

IV. Provider business mailing address

4234 RIVERWALK PKWY STE 230
RIVERSIDE CA
92505-3312
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-3672
  • Fax: 951-781-0365
Mailing address:
  • Phone: 951-781-3672
  • Fax: 951-781-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number81611
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number81611
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA87174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: