Provider Demographics
NPI:1386612083
Name:CANAVERO, DINA MARIE (MEDICAL DOCTOR)
Entity type:Individual
Prefix:
First Name:DINA
Middle Name:MARIE
Last Name:CANAVERO
Suffix:
Gender:F
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2868
Mailing Address - Country:US
Mailing Address - Phone:916-782-2229
Mailing Address - Fax:916-797-9414
Practice Address - Street 1:5 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 250
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2868
Practice Address - Country:US
Practice Address - Phone:916-782-2229
Practice Address - Fax:916-797-9414
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65749207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A657490Medicaid
CA00A657490Medicaid
CAG79218Medicare UPIN