Provider Demographics
NPI:1528063187
Name:MCCANLESS, JAMES W (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:MCCANLESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1485
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81002-1485
Mailing Address - Country:US
Mailing Address - Phone:719-543-8777
Mailing Address - Fax:719-543-7882
Practice Address - Street 1:650 DITTMER AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:719-565-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27112207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01271121Medicaid
184628Medicare ID - Type Unspecified
CO01271121Medicaid