Healthcare Provider Details

I. General information

NPI: 1568084150
Provider Name (Legal Business Name): ETNY RAUL CANDELARIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PERKINS FARM DR STE 203
MYSTIC CT
06355-4041
US

IV. Provider business mailing address

1339 FAIR AVE
SAN ANTONIO TX
78223-1437
US

V. Phone/Fax

Practice location:
  • Phone: 860-576-8911
  • Fax: 860-572-7758
Mailing address:
  • Phone: 210-923-4372
  • Fax: 210-923-5581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301510053
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU6458
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number79070
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: