Provider Demographics
NPI:1194700286
Name:CANULLA, MARCO VALERIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARCO
Middle Name:VALERIO
Last Name:CANULLA
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 21647
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-1647
Mailing Address - Country:US
Mailing Address - Phone:405-696-0030
Mailing Address - Fax:
Practice Address - Street 1:14044 W CAMELBACK RD STE 118
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9481
Practice Address - Country:US
Practice Address - Phone:623-584-4882
Practice Address - Fax:623-584-6732
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38460208600000X
AZ24230208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ348583Medicaid
AZ348583Medicaid
Z112387Medicare PIN