Provider Demographics
NPI:1740208552
Name:CANNON, CAROLYN L (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:L
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:LOUISE
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD PHD
Mailing Address - Street 1:2900 E 29TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2623
Mailing Address - Country:US
Mailing Address - Phone:979-436-0501
Mailing Address - Fax:979-776-6905
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-456-2857
Practice Address - Fax:214-456-5406
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030148382080P0201X
TXN43222080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209230002Medicaid
P00103745Medicare PIN
G99575Medicare UPIN
315010381Medicare PIN