Provider Demographics
NPI:1588722854
Name:CANAAN, ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:CANAAN
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 1:1220 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2810
Mailing Address - Country:US
Mailing Address - Phone:386-236-3200
Mailing Address - Fax:386-236-3161
Practice Address - Street 1:1220 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2810
Practice Address - Country:US
Practice Address - Phone:386-236-3200
Practice Address - Fax:386-236-3161
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME604872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14325OtherBCBS
FL056828700Medicaid
FL14325Medicare ID - Type Unspecified
FL056828700Medicaid