Healthcare Provider Details

I. General information

NPI: 1881805265
Provider Name (Legal Business Name): MARK LAWRENCE CANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N
ROBBINSDALE MN
55422-2948
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-5200
  • Fax: 763-581-6401
Mailing address:
  • Phone: 763-520-5200
  • Fax: 763-581-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number206201
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number4301061767
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number39619
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: