Basic Information
Provider Information | |||||||||
NPI: | 1295998037 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CANILLAS | ||||||||
FirstName: | MARTIN | ||||||||
MiddleName: | ROJAS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14690 SPRING HILL DR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | SPRING HILL | ||||||||
State: | FL | ||||||||
PostalCode: | 346098102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527990046 | ||||||||
FaxNumber: | 3527990042 | ||||||||
Practice Location | |||||||||
Address1: | 14555 CORTEZ BLVD | ||||||||
Address2: |   | ||||||||
City: | BROOKSVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 346136003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525564823 | ||||||||
FaxNumber: | 3525564824 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2008 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
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 | 207QS0010X | ME123994 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 26447 | OK | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1213R | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 015444400 | 05 | FL |   | MEDICAID |