Provider Demographics
NPI:1376170944
Name:CANNON, MARYURI BRICENO (MD)
Entity Type:Individual
Prefix:
First Name:MARYURI
Middle Name:BRICENO
Last Name:CANNON
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 1:11684 WHITE DOGWOOD RD # 32256
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8188
Mailing Address - Country:US
Mailing Address - Phone:786-683-7852
Mailing Address - Fax:
Practice Address - Street 1:653-1 W 8TH ST FL 4
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-633-4199
Practice Address - Fax:904-633-4188
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLME161065208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program