=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356565519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE R CANARIO JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 04/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7150 MAIN ST
-----------------------------------------------------
City | OVID
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14521-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-403-0065
-----------------------------------------------------
Fax | 607-403-0093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 423
-----------------------------------------------------
City | PENN YAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14527-0423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-531-9102
-----------------------------------------------------
Fax | 315-531-9103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 243042
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------