Provider Demographics
NPI:1013025568
Name:CANNON, CRAIG FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:FREDERICK
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4351 E LOHMAN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8260
Mailing Address - Country:US
Mailing Address - Phone:575-522-2233
Mailing Address - Fax:575-522-2266
Practice Address - Street 1:4351 E LOHMAN AVE STE 201
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8260
Practice Address - Country:US
Practice Address - Phone:575-522-2233
Practice Address - Fax:575-522-2266
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM93234207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK0715Medicaid
NMK0715Medicaid
NM700521019Medicare PIN