Provider Demographics
NPI:1306979828
Name:CANEDO, JOSE ALFONSO (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ALFONSO
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 1:2300 MANCHESTER EXPY
Mailing Address - Street 2:BLDG H SUITE 103
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-571-0121
Mailing Address - Fax:706-571-0124
Practice Address - Street 1:2300 MANCHESTER EXPY
Practice Address - Street 2:BLDG H SUITE 103
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6802
Practice Address - Country:US
Practice Address - Phone:706-571-0121
Practice Address - Fax:706-571-0124
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0323562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00416435AMedicaid
GA13BDBZGMedicare ID - Type UnspecifiedMEDICARE
GA00416435AMedicaid