Healthcare Provider Details

I. General information

NPI: 1790987568
Provider Name (Legal Business Name): CARLOS R CANIZALES MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 N 13TH AVE SUITE 9
UPLAND CA
91786-4916
US

IV. Provider business mailing address

305 N. 2ND AVENUE SUITE 203
UPLAND CA
91786
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-5923
  • Fax: 909-920-3054
Mailing address:
  • Phone: 909-981-5923
  • Fax: 909-920-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLOS R CANIZALES
Title or Position: OWNER
Credential: M.D.
Phone: 909-981-5923