Basic Information
| Provider Information | |||||||||
| NPI: | 1285629857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANIZARES | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | RAMOS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11131 JOURNAL PKWY | ||||||||
| Address2: | |||||||||
| City: | KING GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224853468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406252527 | ||||||||
| FaxNumber: | 5407097211 | ||||||||
| Practice Location | |||||||||
| Address1: | 11131 JOURNAL PKWY | ||||||||
| Address2: | |||||||||
| City: | KING GEORGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224853468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406252527 | ||||||||
| FaxNumber: | 5407097211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 0101025116 | VA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 501033 | 01 | VA | AETNA | OTHER | 4091663 | 01 | VA | AETNA | OTHER | 001368 | 01 | VA | ANTHEM BCBS | OTHER |