Provider Demographics
NPI:1790947083
Name:CANNON, CHAD MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:CANNON
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:P.O. BOX 235019
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5019
Mailing Address - Country:US
Mailing Address - Phone:800-232-5703
Mailing Address - Fax:918-748-7688
Practice Address - Street 1:8131 S. MEMORIAL DRIVE
Practice Address - Street 2:SUITE 107
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4348
Practice Address - Country:US
Practice Address - Phone:918-252-5114
Practice Address - Fax:918-748-7688
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK26477207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology