Healthcare Provider Details

I. General information

NPI: 1124080106
Provider Name (Legal Business Name): MICHAEL TODD CANNON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W 9TH ST
TULSA OK
74127-9907
US

IV. Provider business mailing address

11820 N 177TH EAST AVE
COLLINSVILLE OK
74021-5149
US

V. Phone/Fax

Practice location:
  • Phone: 918-561-5720
  • Fax:
Mailing address:
  • Phone: 918-688-4762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4284
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: