MEDICARE: MARK J CANNON OD PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD60160060	WA

General Provider Information

NPI Number	:	1265789390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK J CANNON OD PS

Provider Business Mailing Address
First Line	:	134 CENTRAL WAY
Second Line	:	WASHINGTON PACIFIC EYE ASSOCIATES
City	:	KIRKLAND
State	:	WA
Zip	:	98033-6106
Country	:	US
Telephone Number	:	425-889-2020
Fax Number	:	425-739-0601

Provider Business Practice Location Address
First Line	:	134 CENTRAL WAY
Second Line	:	WASHINGTON PACIFIC EYE ASSOCIATES
City	:	KIRKLAND
State	:	WA
Zip	:	98033-6106
Country	:	US
Telephone Number	:	425-889-2020
Fax Number	:	425-739-0601

Authorized Official
Title or Position	:	CHIEF OF OPTOMETRY
Name	:	DR. MARK J CANNON
Credential	:	O.D.
Telephone Number	:	206-714-8445

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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