Healthcare Provider Details

I. General information

NPI: 1073519815
Provider Name (Legal Business Name): CHARLES LAWRENCE CANNON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1218 W WILLOW STE A
ENID OK
73703-2534
US

IV. Provider business mailing address

1218 W WILLOW RD STE A
ENID OK
73703-2534
US

V. Phone/Fax

Practice location:
  • Phone: 580-233-2176
  • Fax: 580-233-2179
Mailing address:
  • Phone: 580-233-2176
  • Fax: 580-233-2179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number17275
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: