Provider Demographics
NPI:1922494673
Name:CANNON, MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E ZAVALA ST
Mailing Address - Street 2:STE 3
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78839-3337
Mailing Address - Country:US
Mailing Address - Phone:720-252-7546
Mailing Address - Fax:
Practice Address - Street 1:402 E ZAVALA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78839-3337
Practice Address - Country:US
Practice Address - Phone:720-252-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2169213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3520348-01Medicaid