Healthcare Provider Details

I. General information

NPI: 1588786784
Provider Name (Legal Business Name): JUAN GABRIEL PENARANDA CANAL M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 636324
CINCINNATI OH
45263-6324
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-9010
  • Fax: 859-301-9018
Mailing address:
  • Phone: 859-301-9010
  • Fax: 859-301-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301085374
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number32425
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number60150
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: