Provider Demographics
NPI:1326032939
Name:CANNON, PETER M (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2001 S WOODRUFF AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6374
Mailing Address - Country:US
Mailing Address - Phone:208-524-4511
Mailing Address - Fax:208-524-4540
Practice Address - Street 1:2001 S WOODRUFF AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6374
Practice Address - Country:US
Practice Address - Phone:208-524-4511
Practice Address - Fax:208-524-4540
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3494208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002502000Medicaid
ID1111220Medicare ID - Type Unspecified
ID002502000Medicaid