Provider Demographics
NPI:1811252679
Name:CANNON, GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 CHEW ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5549
Mailing Address - Country:US
Mailing Address - Phone:610-969-3500
Mailing Address - Fax:610-969-3605
Practice Address - Street 1:1730 CHEW ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5549
Practice Address - Country:US
Practice Address - Phone:610-969-3500
Practice Address - Fax:610-969-3605
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine