Provider Demographics
NPI:1316925514
Name:CANALIS, ERNESTO (MD)
Entity type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:CANALIS
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-3245
Mailing Address - Fax:860-679-1217
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-5351
Practice Address - Country:US
Practice Address - Phone:860-679-3245
Practice Address - Fax:860-679-1217
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016393207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316925514Medicaid