Provider Demographics
NPI:1437261088
Name:CANNON, GEORGE L (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
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:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:13000 N 103RD AVE
Practice Address - Street 2:#97
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3060
Practice Address - Country:US
Practice Address - Phone:623-933-1337
Practice Address - Fax:623-933-6109
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ173947Medicare PIN