Healthcare Provider Details

I. General information

NPI: 1528097045
Provider Name (Legal Business Name): ROBERT JAMES CANNON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 JACKSON ST
RIVERSIDE CA
92503-3919
US

IV. Provider business mailing address

11 STONEGATE
IRVINE CA
92602-2451
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-5666
  • Fax: 951-352-5445
Mailing address:
  • Phone: 949-734-3363
  • Fax: 949-294-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA39500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: