Healthcare Provider Details

I. General information

NPI: 1376170944
Provider Name (Legal Business Name): MARYURI BRICENO CANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653-1 W 8TH ST FL 4
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

11684 WHITE DOGWOOD RD # 32256
JACKSONVILLE FL
32256-8188
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-4199
  • Fax: 904-633-4188
Mailing address:
  • Phone: 786-683-7852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME161065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: