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General NPI Number Information
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NPI Number | 1942512942
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Entity Type | Organization
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Legal Business Name | MARY JO CANNON MD
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Dates
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Enumeration Date | 07/07/2010
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Last Update Date | 02/07/2013
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Provider Practice Location Address
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Address Line | 20909 SUNNYACRES RD
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City | GAITHERSBURG
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State | MD
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Zip | 20882-1248
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Country | US
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Telephone | 240-683-0015
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Fax |
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Provider Business Mailing Address
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Address Line | 20909 SUNNYACRES RD
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City | GAITHERSBURG
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State | MD
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Zip | 20882-1248
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Country | US
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Telephone | 240-683-0015
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Fax |
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Authorized Official
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Title or Position | PRACTITIONER
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Name | DR. MARY JO CANNON
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Credential | M.D.
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Telephone | 240-330-2430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number | D28907
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License Number State | MD
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