MEDICARE: MICHAEL B CANNON MD

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	208600000X	Surgery Physician	17716	OK
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	K8048	TX
3	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	17716	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	87491N	OTHER	TX	BL TX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750376026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL B CANNON MD

Provider Business Mailing Address
First Line	:	7800 NW 85TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73132-3385
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5224 E I 240 SERVICE RD STE 201
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-2607
Country	:	US
Telephone Number	:	405-608-3800
Fax Number	:	405-242-5962

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	06/06/2022

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Directions to “ MICHAEL B CANNON MD” Practice Location

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