Provider Demographics
NPI:1184734451
Name:CANNON, KATRINA TERESE (MD, MS, CMD)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:TERESE
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD, MS, CMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1345 W CENTRAL PARK AVE
Mailing Address - Street 2:GENESIS FAMILY MEDICINE CENTER
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1844
Mailing Address - Country:US
Mailing Address - Phone:563-421-4400
Mailing Address - Fax:563-421-4449
Practice Address - Street 1:1345 W CENTRAL PARK AVE
Practice Address - Street 2:GENESIS FAMILY MEDICINE CENTER
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1844
Practice Address - Country:US
Practice Address - Phone:563-421-4400
Practice Address - Fax:563-421-4449
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA35725207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0732552Medicaid
IA26710OtherWELLMARK BCBS
IA26710OtherWELLMARK BCBS
I62684Medicare UPIN