Provider Demographics
NPI:1528194321
Name:JAY CANNON MD PC
Entity Type:Organization
Organization Name:JAY CANNON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:P
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-945-4240
Mailing Address - Street 1:3435 NW 56TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4414
Mailing Address - Country:US
Mailing Address - Phone:405-945-4240
Mailing Address - Fax:405-945-4242
Practice Address - Street 1:3435 NW 56TH ST STE 210
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4414
Practice Address - Country:US
Practice Address - Phone:405-945-4240
Practice Address - Fax:405-945-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9490208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100104400AMedicaid
OK=========OtherFEDERAL TIN
OK=========OtherFEDERAL TIN
OK100104400AMedicaid
OK800522197Medicare ID - Type Unspecified