Provider Demographics
NPI:1689738262
Name:CANNON, PATRICK J (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:CANNON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:16101 VENTURA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2500
Mailing Address - Country:US
Mailing Address - Phone:818-788-5700
Mailing Address - Fax:818-788-5702
Practice Address - Street 1:16101 VENTURA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2500
Practice Address - Country:US
Practice Address - Phone:818-788-5700
Practice Address - Fax:818-788-5702
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
CAG29054208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91170Medicare UPIN