Provider Demographics
NPI:1801356548
Name:CANALS RIVERA, MARILIAN A (MD)
Entity type:Individual
Prefix:
First Name:MARILIAN
Middle Name:A
Last Name:CANALS RIVERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5156
Mailing Address - Country:US
Mailing Address - Phone:904-639-2112
Mailing Address - Fax:
Practice Address - Street 1:2021 PROFESSIONAL CENTER DR # 100
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4461
Practice Address - Country:US
Practice Address - Phone:904-688-3000
Practice Address - Fax:904-688-3001
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME152936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program