MEDICARE: JAY CANNON MD PC

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	208600000X	Surgery Physician	9490	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528194321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAY CANNON MD PC

Provider Business Mailing Address
First Line	:	3435 NW 56TH ST STE 210
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4414
Country	:	US
Telephone Number	:	405-945-4240
Fax Number	:	405-945-4242

Provider Business Practice Location Address
First Line	:	3435 NW 56TH ST STE 210
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4414
Country	:	US
Telephone Number	:	405-945-4240
Fax Number	:	405-945-4242

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAY P CANNON
Credential	:	MD
Telephone Number	:	405-945-4240

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	06/17/2008

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