Provider Demographics
NPI:1801657093
Name:CANEVARO, EDGARD (ABOC)
Entity type:Individual
Prefix:
First Name:EDGARD
Middle Name:
Last Name:CANEVARO
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-3623
Mailing Address - Country:US
Mailing Address - Phone:818-786-0758
Mailing Address - Fax:
Practice Address - Street 1:5908 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-3623
Practice Address - Country:US
Practice Address - Phone:818-786-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA238704156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician