Provider Demographics
NPI:1891802435
Name:CANNON, CARI (OD)
Entity Type:Individual
Prefix:
First Name:CARI
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1945
Mailing Address - Country:US
Mailing Address - Phone:617-323-0200
Mailing Address - Fax:
Practice Address - Street 1:1819 CENTRE ST
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-1945
Practice Address - Country:US
Practice Address - Phone:617-323-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW17560Medicare ID - Type Unspecified
MAV02669Medicare UPIN