Provider Demographics
NPI:1073647962
Name:JOE RONALD CANNON
Entity Type:Organization
Organization Name:JOE RONALD CANNON
Other - Org Name:ABILENE DERMATOPATHOLOGY LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DERMATOPATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-672-2162
Mailing Address - Street 1:PO BOX 3611
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-3611
Mailing Address - Country:US
Mailing Address - Phone:325-672-2162
Mailing Address - Fax:
Practice Address - Street 1:802 ORANGE ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-4020
Practice Address - Country:US
Practice Address - Phone:325-672-2162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2498291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX025322101Medicaid
TXCL0449OtherBLUE CROSS
TXCL0449OtherBLUE CROSS