Provider Demographics
NPI:1831276286
Name:CANNON, SHAWN PATRICK (DO)
Entity type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:PATRICK
Last Name:CANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:WAINSCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:11975-0097
Mailing Address - Country:US
Mailing Address - Phone:631-267-5373
Mailing Address - Fax:631-267-5376
Practice Address - Street 1:518 MONTAUK HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:AMAGANSETT
Practice Address - State:NY
Practice Address - Zip Code:11930-2110
Practice Address - Country:US
Practice Address - Phone:631-267-5373
Practice Address - Fax:631-267-5376
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01837136Medicaid
NY01837136Medicaid
NY367611Medicare ID - Type Unspecified