Healthcare Provider Details

I. General information

NPI: 1790179653
Provider Name (Legal Business Name): AUSTIN RON CANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

7417 S RICH WAY
COTTONWOOD HEIGHTS UT
84121-4840
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7000
  • Fax:
Mailing address:
  • Phone: 919-608-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number10086826-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: