Provider Demographics
NPI:1275205437
Name:CANNON, BENJAMIN CHAD (CPRS)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:CHAD
Last Name:CANNON
Suffix:
Gender:M
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 E LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1866
Mailing Address - Country:US
Mailing Address - Phone:423-530-8309
Mailing Address - Fax:
Practice Address - Street 1:2408 SUSANNAH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1732
Practice Address - Country:US
Practice Address - Phone:423-434-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000027637207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine