Healthcare Provider Details

I. General information

NPI: 1700874179
Provider Name (Legal Business Name): JERROLD S. CANAKIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10344 OLD OCN BLVD
BERLIN MD
21811
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-641-2938
  • Fax: 410-641-4904
Mailing address:
  • Phone: 410-546-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC10006596
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberD0059594
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: