Provider Demographics
NPI:1124036231
Name:CANNON, MAX KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:KENT
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-0508
Mailing Address - Country:US
Mailing Address - Phone:801-465-1701
Mailing Address - Fax:801-465-1707
Practice Address - Street 1:39 PROFESSIONAL WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1675
Practice Address - Country:US
Practice Address - Phone:801-465-1701
Practice Address - Fax:801-465-1707
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT97-347-228-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT101271OtherIHC-UT/ALL USA
UT101271OtherIHC-UT/ALL USA