Provider Demographics
NPI:1760547400
Name:CANNON, CARRIE SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:SUE
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14968 FAVERSHAM CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4109
Mailing Address - Country:US
Mailing Address - Phone:407-808-2373
Mailing Address - Fax:
Practice Address - Street 1:8010 WEST COLONIAL DR.
Practice Address - Street 2:UNIT #146-162
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818
Practice Address - Country:US
Practice Address - Phone:407-434-8080
Practice Address - Fax:407-434-8084
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89284207Q00000X
TXH7277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4591ZMedicare ID - Type Unspecified
F68316Medicare UPIN
TX85M698Medicare ID - Type Unspecified