Healthcare Provider Details

I. General information

NPI: 1982920401
Provider Name (Legal Business Name): KIM DAVID O. CANLAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MEDICAL PLAZA DR SUITE 140
ROSEVILLE CA
95661-3087
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-797-4715
  • Fax: 916-797-4716
Mailing address:
  • Phone: 855-771-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA122411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: