Provider Demographics
NPI:1376569210
Name:CANNON, DOUGLAS TODD (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:TODD
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 1:1400 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2205
Mailing Address - Country:US
Mailing Address - Phone:901-759-3100
Mailing Address - Fax:901-759-3196
Practice Address - Street 1:8000 CENTERVIEW PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4227
Practice Address - Country:US
Practice Address - Phone:901-759-3100
Practice Address - Fax:901-759-3196
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS228762081P2900X
TN50010208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05254852Medicaid
TNQ004010Medicaid
AR199076001Medicaid
MS100295624Medicaid