Healthcare Provider Details

I. General information

NPI: 1730228214
Provider Name (Legal Business Name): CHARLES BERNARD MCCANNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLES BERNARD MCCANNA MD

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 ZAFARANO DR STE C
SANTA FE NM
87507-2669
US

IV. Provider business mailing address

2063 PLACITA DE VIDA
SANTA FE NM
87505-5488
US

V. Phone/Fax

Practice location:
  • Phone: 505-466-5885
  • Fax: 505-466-5886
Mailing address:
  • Phone: 505-946-8790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNM 76-67
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number76-67
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: