MEDICARE: DR. MARIA CECILIA S CANLAS 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	207R00000X	Internal Medicine Physician	200301210	NC
2	207R00000X	Internal Medicine Physician	A90534	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7308694	OTHER	CA	AETNA ID

General Provider Information

NPI Number	:	1558362905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIA CECILIA S CANLAS MD

Provider Business Mailing Address
First Line	:	23517 MAIN ST
Second Line	:	SUITE 108
City	:	CARSON
State	:	CA
Zip	:	90745-5251
Country	:	US
Telephone Number	:	310-518-6246
Fax Number	:	310-518-6247

Provider Business Practice Location Address
First Line	:	23517 MAIN ST
Second Line	:	SUITE 108
City	:	CARSON
State	:	CA
Zip	:	90745-5251
Country	:	US
Telephone Number	:	310-518-6246
Fax Number	:	310-518-6247

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

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	11/19/2010

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