Provider Demographics
NPI:1255335147
Name:CANNON, WOODWARD (MD)
Entity type:Individual
Prefix:DR
First Name:WOODWARD
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 BLUE RIDGE RD
Mailing Address - Street 2:STE 503
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6477
Mailing Address - Country:US
Mailing Address - Phone:919-782-8210
Mailing Address - Fax:919-781-4650
Practice Address - Street 1:2800 BLUE RIDGE RD
Practice Address - Street 2:STE 503
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6477
Practice Address - Country:US
Practice Address - Phone:919-782-8210
Practice Address - Fax:919-781-4650
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21631208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8921061Medicaid
NC21061OtherBCBS
NC201932CMedicare PIN
C80977Medicare UPIN
NC8921061Medicaid