Provider Demographics
NPI:1083777908
Name:CANNON, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1325 WRIGHT AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-2226
Mailing Address - Country:US
Mailing Address - Phone:337-783-4043
Mailing Address - Fax:337-783-4053
Practice Address - Street 1:1325 WRIGHT AVE STE A
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2226
Practice Address - Country:US
Practice Address - Phone:337-783-4043
Practice Address - Fax:337-783-4053
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA025690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1048577Medicaid
LA2372793Medicaid
LA2372793Medicaid
LA1048577Medicaid