Provider Demographics
NPI:1770594723
Name:CANNON, SARA M (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4096
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:217-277-2253
Practice Address - Street 1:1118 HAMPSHIRE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3027
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:217-277-2253
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036116347207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
036166347OtherSTATE LICENSE
ILF400192445Medicare PIN