Provider Demographics
NPI:1912971243
Name:CANNON, WILLIAM J (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1233
Practice Address - Country:US
Practice Address - Phone:920-563-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36081211207R00000X
WI65437207R00000X
WI65437-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36081211Medicaid
ILL80171Medicare ID - Type Unspecified
IL995170Medicare ID - Type Unspecified
IL36081211Medicaid
F59181Medicare PIN