Healthcare Provider Details

I. General information

NPI: 1639447642
Provider Name (Legal Business Name): CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WATERS AVE SUITE 512
SAVANNAH GA
31404-6200
US

IV. Provider business mailing address

4750 WATERS AVE SUITE 512
SAVANNAH GA
31404-6200
US

V. Phone/Fax

Practice location:
  • Phone: 912-547-1091
  • Fax:
Mailing address:
  • Phone: 912-547-1091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CLIFTON LAMAR CANNON III
Title or Position: OWNER
Credential: MD
Phone: 912-547-1091