Basic Information
| Provider Information | |||||||||
| NPI: | 1982080339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANO CEVALLOS | ||||||||
| FirstName: | EDISON | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765685 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 5647 HOLLYWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330216325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542761616 | ||||||||
| FaxNumber: | 9542760186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2015 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME151652 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 63792 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RI0200X | ME151652 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 111150900 | 05 | FL | MEDICAID |