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NPI Code Detail

MEDICARE: DR. JUAN R CANIZALES O.D.

MEDICARE: DR. JUAN R CANIZALES O.D.
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
1152W00000XOptometristOPC4007FL
2152W00000XOptometrist2129NC
3152W00000XOptometrist740HI

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00369116OTHERFLRAIL ROAD MEDICARE

General Provider Information

NPI Number : 1912996984
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JUAN R CANIZALES O.D.
Provider Business Mailing Address
First Line : 330 BILLINGSLEY RD STE 205
Second Line :
City : CHARLOTTE
State : NC
Zip : 28211-5020
Country : US
Telephone Number : 704-366-0223
Fax Number : 704-366-5327
Provider Business Practice Location Address
First Line : 12731 NEW BRITTANY BLVD
Second Line :
City : FORT MYERS
State : FL
Zip : 33907-3632
Country : US
Telephone Number : 239-418-0999
Fax Number : 239-274-0773
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/20/2005
Last Update Date : 07/22/2013

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