Provider Demographics
NPI:1124412085
Name:CANNON, VICTORIA AUGUSTA (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:AUGUSTA
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5780
Mailing Address - Country:US
Mailing Address - Phone:800-348-4565
Mailing Address - Fax:888-203-4247
Practice Address - Street 1:5101 COLLINS AVE APT 14N
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2727
Practice Address - Country:US
Practice Address - Phone:800-348-4565
Practice Address - Fax:888-203-4247
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2025-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20210473672084N0400X
NMMD2023-15162084N0400X
FLME1766652084N0400X
CAA1626762084N0400X
CODR.00671312084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05631036Medicaid