Provider Demographics
NPI:1073519815
Name:CANNON, CHARLES LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LAWRENCE
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 W WILLOW RD
Mailing Address - Street 2:STE A
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2534
Mailing Address - Country:US
Mailing Address - Phone:580-233-2176
Mailing Address - Fax:580-233-2179
Practice Address - Street 1:1218 W WILLOW
Practice Address - Street 2:STE A
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2534
Practice Address - Country:US
Practice Address - Phone:580-233-2176
Practice Address - Fax:580-233-2179
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2012-12-11
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OK17275207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100007598OtherRAILROAD MEDICARE
OK0000OtherTRICARE REGION 6
OK100088540AMedicaid
F30414Medicare UPIN