Provider Demographics
NPI:1225343072
Name:CANNON, NATHAN ALLEN (MD/PHD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALLEN
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7910 W JEFFERSON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-4116
Mailing Address - Fax:
Practice Address - Street 1:11050 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845
Practice Address - Country:US
Practice Address - Phone:260-266-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075113A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201292540Medicaid
OH0134869Medicaid
IN201292540Medicaid
IN132510003Medicare PIN