MEDICARE: DWIGHT CANNON

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	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1639884448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWIGHT CANNON

Provider Business Mailing Address
First Line	:	4397 ARDMORE RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44121-3620
Country	:	US
Telephone Number	:	216-710-9786
Fax Number	:

Provider Business Practice Location Address
First Line	:	4397 ARDMORE RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44121-3620
Country	:	US
Telephone Number	:	216-710-9786
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2023
Last Update Date	:	01/16/2023

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Directions to “ DWIGHT CANNON ” Practice Location

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