Provider Demographics
NPI:1467445726
Name:CANON, PATRICK KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:KEVIN
Last Name:CANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:P
Other - Middle Name:KEVIN
Other - Last Name:CANON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3155 N UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8703
Mailing Address - Country:US
Mailing Address - Phone:719-219-1312
Mailing Address - Fax:719-635-3578
Practice Address - Street 1:3155 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-8703
Practice Address - Country:US
Practice Address - Phone:719-219-1312
Practice Address - Fax:719-635-3578
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0427635207W00000X
MO112821207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00162955OtherRAILROAD MEDICARE
406C842BMedicare PIN
P00162955OtherRAILROAD MEDICARE