Provider Demographics
NPI:1750376026
Name:CANNON, MICHAEL B (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
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 1:7800 NW 85TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5224 E I 240 SERVICE RD STE 201
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2607
Practice Address - Country:US
Practice Address - Phone:405-608-3800
Practice Address - Fax:405-242-5962
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17716208600000X, 208G00000X
TXK8048208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87491NOtherBL TX
OK100137740AMedicaid
AR138370001Medicaid
TX045603002Medicaid
AR138370001Medicaid
OK529813YMU8Medicare PIN