MEDICARE: DR. MARA LISSETH CANALES MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	024168	PR

General Provider Information

NPI Number	:	1104641885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARA LISSETH CANALES MD

Provider Business Mailing Address
First Line	:	5505 NW 7TH ST APT W214
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3207
Country	:	US
Telephone Number	:	786-461-9392
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 NW 7TH ST APT W214
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3207
Country	:	US
Telephone Number	:	786-461-9392
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2024
Last Update Date	:	11/19/2024

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