Provider Demographics
NPI:1164764759
Name:CANNON, WILLIAM RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RUSSELL
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 1:2321 BLUE RIDGE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6453
Mailing Address - Country:US
Mailing Address - Phone:919-845-1555
Mailing Address - Fax:919-845-1558
Practice Address - Street 1:2321 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-0163
Practice Address - Country:US
Practice Address - Phone:919-845-1555
Practice Address - Fax:919-845-1558
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC005682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program