Basic Information
| Provider Information | |||||||||
| NPI: | 1184771347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANCHOLA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | RAMIRO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7200 STATE HIGHWAY 161 STE 300 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750393831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724435300 | ||||||||
| FaxNumber: | 9724320498 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 STATE HIGHWAY 161 STE 300 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750393831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724435300 | ||||||||
| FaxNumber: | 9724320498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME112104 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 49540 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54537 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | E-10703 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | K7137 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | TM2010-0736 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2011-00164 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2010042080 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1458 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301097537 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 249804 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 44505 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 07078685A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036128916 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 065528 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0434728 | 01 | KS | STATE MEDICAL LICENSE | OTHER | 124189506 | 05 | TX | MEDICAID | 036128916 | 01 | IL | STATE MEDICAL LICENSE | OTHER | 32869 | 01 | OK | STATE MEDICAL LICENSE | OTHER | MD10238 | 01 | SD | STATE MEDICAL LICENSE | OTHER | 124189507 | 05 | TX | MEDICAID | 35.096267 | 01 | OH | STATE MEDICAL LICENSE | OTHER | 0101250406 | 01 | VA | STATE MEDICAL LICENSE | OTHER | 7792324-1205 | 01 | UT | STATE MEDICAL LICENSE | OTHER | MD441759 | 01 | PA | STATE MEDICAL LICENSE | OTHER | 24737 | 01 | WV | STATE MEDICAL LICENSE | OTHER | 25691 | 01 | MS | STATE MEDICAL LICENSE | OTHER | 55352 | 01 | TN | STATE MEDICAL LICENSE | OTHER |