Provider Demographics
NPI:1841233434
Name:CANNON, AILEEN CAROL (MD)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:CAROL
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:SHS 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-6750
Practice Address - Country:US
Practice Address - Phone:813-974-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114340208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006793600Medicaid
NY02611136Medicaid
FL14N3QOtherBLUE CROSS BLUE SHIELD
NY02611136Medicaid