Provider Demographics
NPI:1063415826
Name:CANNON, HAROLD C JR (MD)
Entity type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:C
Last Name:CANNON
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG D SUITE 100
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-688-1770
Mailing Address - Fax:270-688-1780
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG D SUITE 100
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-688-1770
Practice Address - Fax:270-688-1780
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2013-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01036413A174400000X
KY22288174400000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000388450OtherANTHEM
KY64222888Medicaid
IN100015240AMedicaid
KY0000388450OtherANTHEM
C67955Medicare UPIN
IN100015240AMedicaid
KY649905Medicare PIN
IN202280CMedicare PIN