Provider Demographics
NPI:1568549996
Name:CANNON, DEIRDRE BRIANNE (PAC)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:BRIANNE
Last Name:CANNON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 HAWLEY LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5300
Mailing Address - Country:US
Mailing Address - Phone:203-377-0639
Mailing Address - Fax:203-386-9706
Practice Address - Street 1:160 HAWLEY LN
Practice Address - Street 2:SUITE 104
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-5300
Practice Address - Country:US
Practice Address - Phone:203-377-0639
Practice Address - Fax:203-386-9706
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001826207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
970002535Medicare PIN