Provider Demographics
NPI:1356456503
Name:PAUL B CANNON DPM PC
Entity Type:Organization
Organization Name:PAUL B CANNON DPM PC
Other - Org Name:FALLS CHURCH FOOT AND ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-237-1555
Mailing Address - Street 1:104A E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4501
Mailing Address - Country:US
Mailing Address - Phone:703-237-1555
Mailing Address - Fax:703-237-2253
Practice Address - Street 1:104A E BROAD ST
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4501
Practice Address - Country:US
Practice Address - Phone:703-237-1555
Practice Address - Fax:703-237-2253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300931213ES0103X
VA0893300001332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG02077Medicare PIN
VA0893300001Medicare NSC