Provider Demographics
NPI:1679532592
Name:CANNON, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:101 STADIUM DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-7911
Practice Address - Country:US
Practice Address - Phone:304-598-4000
Practice Address - Fax:304-293-6963
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV205062085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1807576000Medicaid
WV1807576000Medicaid
WVCA6030613Medicare ID - Type Unspecified