Provider Demographics
NPI:1053575159
Name:MITRA CANALES M.D. P.A.
Entity type:Organization
Organization Name:MITRA CANALES M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGHIRI-CANALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-469-0022
Mailing Address - Street 1:4401 COIT RD STE 303
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0508
Mailing Address - Country:US
Mailing Address - Phone:214-469-0022
Mailing Address - Fax:214-469-0028
Practice Address - Street 1:4401 COIT RD STE 303
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-0508
Practice Address - Country:US
Practice Address - Phone:214-469-0022
Practice Address - Fax:214-469-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0018RQOtherBLUE CROSS BLUE SHIELD
TX0018RQOtherBLUE CROSS BLUE SHIELD