MEDICARE: GARY CANNON D.O.

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	207Q00000X	Family Medicine Physician	1937	OK

General Provider Information

NPI Number	:	1659357051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY CANNON D.O.

Provider Business Mailing Address
First Line	:	6600 S YALE AVE STE 1400
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3331
Country	:	US
Telephone Number	:	888-247-0125
Fax Number	:	918-502-8210

Provider Business Practice Location Address
First Line	:	11610 N 137TH E AVE
Second Line	:
City	:	COLLINSVILLE
State	:	OK
Zip	:	74021
Country	:	US
Telephone Number	:	918-272-2247
Fax Number	:	918-272-6185

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

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	01/26/2023

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