MEDICARE: DR. MARK 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
1	2084P0800X	Psychiatry Physician	128000	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306035381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK CANNON M.D.

Provider Business Mailing Address
First Line	:	230 CENTRAL PARK W
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-6029
Country	:	US
Telephone Number	:	212-787-9083
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 CENTRAL PARK W
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-6029
Country	:	US
Telephone Number	:	212-787-9083
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	12/26/2013

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