Provider Demographics
NPI:1497734701
Name:CANNON, OCTAVIA MANETTA (DO)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIA
Middle Name:MANETTA
Last Name:CANNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 TURF LN
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6392
Mailing Address - Country:US
Mailing Address - Phone:517-484-3000
Mailing Address - Fax:517-484-6358
Practice Address - Street 1:1560 TURF LN
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6392
Practice Address - Country:US
Practice Address - Phone:517-484-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900020174400000X
NC99-00020207V00000X
MI5101012864207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101012864OtherMICHIGAN PHYSICIAN LICENSE
NC891197HMedicaid