Healthcare Provider Details

I. General information

NPI: 1871590794
Provider Name (Legal Business Name): ODEST FRANK CANNON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 SE 17TH ST #100
OCALA FL
34471-3968
US

IV. Provider business mailing address

1015 SE 17TH ST #100
OCALA FL
34471-3968
US

V. Phone/Fax

Practice location:
  • Phone: 352-351-3422
  • Fax: 352-351-9129
Mailing address:
  • Phone: 352-351-3422
  • Fax: 352-351-9129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME0052187
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: