Provider Demographics
NPI:1851472872
Name:CANNON, MATTHEW DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:CANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:853 N CHURCH ST STE 510
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3077
Practice Address - Country:US
Practice Address - Phone:864-560-6193
Practice Address - Fax:864-560-1510
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCLL1020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC98233365OtherMEDICARE PIN
SC010204Medicaid
SCLL1020OtherSC LICENSE NUMBER
SCP00734985OtherRAIL ROAD MEDICARE