Provider Demographics
NPI:1265662068
Name:CANNON, BRYAN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAMES
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 1:16555 MANCHESTER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1220
Mailing Address - Country:US
Mailing Address - Phone:636-458-0646
Mailing Address - Fax:
Practice Address - Street 1:16555 MANCHESTER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1220
Practice Address - Country:US
Practice Address - Phone:636-458-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6038207Q00000X
MO2016016732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1265662068Medicaid
MO152800330Medicare PIN