Provider Demographics
NPI:1740285022
Name:CANNON, PAUL B (DPM)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:B
Last Name:CANNON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:104A E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4501
Mailing Address - Country:US
Mailing Address - Phone:703-237-1555
Mailing Address - Fax:703-237-2253
Practice Address - Street 1:104A E BROAD ST
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4501
Practice Address - Country:US
Practice Address - Phone:703-237-1555
Practice Address - Fax:703-237-2253
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300931213ES0103X
MD01424213ES0103X
DCPO1000043213ES0103X
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG02077F01Medicare PIN
VAV04601Medicare UPIN