Healthcare Provider Details

I. General information

NPI: 1063481851
Provider Name (Legal Business Name): CARMENCITA M CANONIZADO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 CHESWICK LN
VIRGINIA BEACH VA
23455-6560
US

IV. Provider business mailing address

4125 CHESWICK LN
VIRGINIA BEACH VA
23455-6560
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-5056
  • Fax:
Mailing address:
  • Phone: 757-499-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101046016
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101046016
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: