Basic Information
| Provider Information | |||||||||
| NPI: | 1275519233 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCANNEL | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108255000 | ||||||||
| FaxNumber: | 3102067826 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 STEIN PLAZA | ||||||||
| Address2: | RM#1-340 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108255000 | ||||||||
| FaxNumber: | 3102067826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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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 | 207W00000X | G75966 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00G759660 | 05 | CA | MEDICAID |