Provider Demographics
NPI:1326187204
Name:CANON, MELANIE MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:MARY
Last Name:CANON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:VT
Mailing Address - Zip Code:05148-9555
Mailing Address - Country:US
Mailing Address - Phone:802-824-6901
Mailing Address - Fax:
Practice Address - Street 1:38 ROUTE 11
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:VT
Practice Address - Zip Code:05148-9555
Practice Address - Country:US
Practice Address - Phone:802-824-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH12586Medicare UPIN