=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568084150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ETNY RAUL CANDELARIO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2020
-----------------------------------------------------
Last Update Date | 08/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 PERKINS FARM DR STE 203
-----------------------------------------------------
City | MYSTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06355-4041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-576-8911
-----------------------------------------------------
Fax | 860-572-7758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1339 FAIR AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78223-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-923-4372
-----------------------------------------------------
Fax | 210-923-5581
-----------------------------------------------------
=====================================================
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 | 4301510053
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | U6458
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 79070
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------