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NPI Code Detail

MEDICARE: DR. JEFFREY ALEXANDER CANNON M.D

MEDICARE: DR. JEFFREY ALEXANDER CANNON M.D
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianL8002TX

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00178727OTHERTXRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2L8002OTHERTXSTATE LICENSE
38P1541OTHERTXBLUE CROSS

General Provider Information

NPI Number : 1174638902
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JEFFREY ALEXANDER CANNON M.D
Provider Business Mailing Address
First Line : 11901 TOEPPERWEIN RD
Second Line : SUITE1201
City : LIVE OAK
State : TX
Zip : 78233-3161
Country : US
Telephone Number : 210-650-9066
Fax Number : 210-650-9067
Provider Business Practice Location Address
First Line : 11901 TOEPPERWEIN RD
Second Line : SUITE1201
City : LIVE OAK
State : TX
Zip : 78233-3161
Country : US
Telephone Number : 210-650-9066
Fax Number : 210-650-9067
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/20/2006
Last Update Date : 07/09/2007

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