Provider Demographics
NPI:1124080106
Name:CANNON, MICHAEL TODD (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TODD
Last Name:CANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 N 177TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-5149
Mailing Address - Country:US
Mailing Address - Phone:918-688-4762
Mailing Address - Fax:
Practice Address - Street 1:11820 N 177TH EAST AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-5149
Practice Address - Country:US
Practice Address - Phone:918-688-4762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4284207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine