Basic Information
| Provider Information | |||||||||
| NPI: | 1073677555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANILLAS | ||||||||
| FirstName: | ELMO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7032959725 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 MEADOWLANDS PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SECAUCAS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018192099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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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 | 174400000X | 25MA05712700 | NJ | Y | Other Service Providers | Specialist | 207L00000X | 25MA05712700 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 5102502 | 05 | NJ | MEDICAID | P01281145 | 01 | NJ | RAILROAD MEDICARE | OTHER |