Healthcare Provider Details

I. General information

NPI: 1346375714
Provider Name (Legal Business Name): CARMEN C. CANLAS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5B DOCTOR'S PARK
HACKETTSTOWN NJ
07840
US

IV. Provider business mailing address

5B DOCTOR'S PARK
HACKETTSTOWN NJ
07840
US

V. Phone/Fax

Practice location:
  • Phone: 908-852-8096
  • Fax: 908-852-5012
Mailing address:
  • Phone: 908-852-8096
  • Fax: 908-852-5012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA02856100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6190006
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier1437150711
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerTYPE I NPI NUMBER

VIII. Authorized Official

Name: MRS. TERRI CARPENTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 908-852-8096