Provider Demographics
NPI:1174638902
Name:CANNON, JEFFREY ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALEXANDER
Last Name:CANNON
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 1:11901 TOEPPERWEIN RD
Mailing Address - Street 2:SUITE1201
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3161
Mailing Address - Country:US
Mailing Address - Phone:210-650-9066
Mailing Address - Fax:210-650-9067
Practice Address - Street 1:11901 TOEPPERWEIN RD
Practice Address - Street 2:SUITE1201
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3161
Practice Address - Country:US
Practice Address - Phone:210-650-9066
Practice Address - Fax:210-650-9067
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00178727OtherRAILROAD MEDICARE
TXL8002OtherSTATE LICENSE
TX8P1541OtherBLUE CROSS
TXL8002OtherSTATE LICENSE
TX8C2061Medicare ID - Type UnspecifiedMEDICATE NUMBER, PERSONAL