Provider Demographics
NPI:1841224334
Name:CANNON, ROBERT MINNICK (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MINNICK
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SUNSET DR
Mailing Address - Street 2:SUITE 503
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2288
Mailing Address - Country:US
Mailing Address - Phone:706-613-1040
Mailing Address - Fax:706-613-9120
Practice Address - Street 1:700 SUNSET DR
Practice Address - Street 2:SUITE 503
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2288
Practice Address - Country:US
Practice Address - Phone:706-613-1040
Practice Address - Fax:706-613-9120
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33046208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00426544AMedicaid
GAE46053Medicare UPIN
GA02BDBHQMedicare ID - Type Unspecified