Healthcare Provider Details

I. General information

NPI: 1881689164
Provider Name (Legal Business Name): ANGEL L CANINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MENDEZ LICIAGA ST
SAN SEBASTIAN PR
00685
US

IV. Provider business mailing address

PO BOX 1590
SAN SEBASTIAN PR
00685-1590
US

V. Phone/Fax

Practice location:
  • Phone: 787-896-1887
  • Fax: 787-896-1887
Mailing address:
  • Phone: 787-896-1887
  • Fax: 787-896-1887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4383
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4383
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: