Provider Demographics
NPI:1730228214
Name:MCCANNA, CHARLES BERNARD (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BERNARD
Last Name:MCCANNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:BERNARD
Other - Last Name:MCCANNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2063 PLACITA DE VIDA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5488
Mailing Address - Country:US
Mailing Address - Phone:505-946-8790
Mailing Address - Fax:
Practice Address - Street 1:3450 ZAFARANO DR
Practice Address - Street 2:STE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2669
Practice Address - Country:US
Practice Address - Phone:505-466-5885
Practice Address - Fax:505-466-5886
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 76-67207Q00000X
NM76-67208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMD35822Medicare UPIN
NMNMA101202Medicare PIN