Provider Demographics
NPI:1104806702
Name:CANNON, ROBERT DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 E JOYCE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5250
Mailing Address - Country:US
Mailing Address - Phone:479-582-2800
Mailing Address - Fax:479-582-2922
Practice Address - Street 1:1708 E JOYCE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5250
Practice Address - Country:US
Practice Address - Phone:479-582-2800
Practice Address - Fax:479-582-2922
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8066207LP2900X
ARC-8066208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127592001Medicaid
G10506Medicare UPIN
AR127592001Medicaid