Provider Demographics
NPI:1164494423
Name:CANNON, BRIAN WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WAYNE
Last Name:CANNON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8810A FARROW RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8802
Mailing Address - Country:US
Mailing Address - Phone:803-741-2010
Mailing Address - Fax:803-741-2011
Practice Address - Street 1:8810A FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8802
Practice Address - Country:US
Practice Address - Phone:803-741-2010
Practice Address - Fax:803-741-2011
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD09701Medicaid
SCU33755Medicare UPIN
SCU337551379Medicare PIN
SCU337556130Medicare PIN