Provider Demographics
NPI:1659373652
Name:CANNIS, TIMOTHY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:L
Last Name:CANNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 28247
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-8247
Mailing Address - Country:US
Mailing Address - Phone:480-967-6500
Mailing Address - Fax:480-967-6540
Practice Address - Street 1:3434 MIDWAY DR
Practice Address - Street 2:STE 1002
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4923
Practice Address - Country:US
Practice Address - Phone:619-225-6200
Practice Address - Fax:619-225-6208
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG034939207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G349390Medicaid
CAB54990Medicare UPIN
CAWG34939BMedicare PIN