Provider Demographics
NPI:1801082409
Name:CANNON, HEATHER (MD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 E MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2348
Mailing Address - Country:US
Mailing Address - Phone:601-656-1001
Mailing Address - Fax:601-656-7555
Practice Address - Street 1:1122 E MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2348
Practice Address - Country:US
Practice Address - Phone:601-656-1001
Practice Address - Fax:601-656-7555
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS22698207Q00000X
AL29398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03123057Medicaid
MS411269YP5GMedicare PIN