Provider Demographics
NPI:1568072122
Name:CANNON, JAMES DANIEL
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DANIEL
Last Name:CANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WINTERGREEN CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9646
Mailing Address - Country:US
Mailing Address - Phone:803-240-5719
Mailing Address - Fax:
Practice Address - Street 1:7801 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-3958
Practice Address - Country:US
Practice Address - Phone:803-647-7638
Practice Address - Fax:803-647-0637
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCI-47105390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program