Provider Demographics
NPI:1548336175
Name:CANEDO, MARIO I (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:I
Last Name:CANEDO
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 1:3000 MEDICAL PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4696
Mailing Address - Country:US
Mailing Address - Phone:813-615-8088
Mailing Address - Fax:813-615-8468
Practice Address - Street 1:3000 MEDICAL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613
Practice Address - Country:US
Practice Address - Phone:813-615-8088
Practice Address - Fax:813-615-8468
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38331207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4084384OtherAETNA
FL211423OtherAVMED
FL592998397COtherHUMANA
FL00657OtherUNIVERSAL
FL060009578OtherRAILROAD MEDICARE
FL069603000Medicaid
FL069603000Medicaid
FL069603000Medicaid