Provider Demographics
NPI:1114979374
Name:CANNELL, JOHN JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JACOB
Last Name:CANNELL
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 1:1411 MARSH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2968
Mailing Address - Country:US
Mailing Address - Phone:805-439-2569
Mailing Address - Fax:805-439-1073
Practice Address - Street 1:1411 MARSH ST STE 203
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2968
Practice Address - Country:US
Practice Address - Phone:805-439-2569
Practice Address - Fax:805-439-1073
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC375472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C375470Medicare ID - Type Unspecified
A72072Medicare UPIN