Healthcare Provider Details

I. General information

NPI: 1437269479
Provider Name (Legal Business Name): CHARLES RON CANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 RIVER OAKS DR
FLOWOOD MS
39232
US

IV. Provider business mailing address

PO BOX 5345
JACKSON MS
39296
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-5244
  • Fax: 601-939-0545
Mailing address:
  • Phone: 601-932-5244
  • Fax: 601-939-0545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number07635
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: