Provider Demographics
NPI:1154348761
Name:CANNON, MICHAEL E (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIGUEL
Other - Middle Name:E
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 221240
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-8240
Mailing Address - Country:US
Mailing Address - Phone:314-325-8925
Mailing Address - Fax:
Practice Address - Street 1:16216 BAXTER RD STE 340
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4778
Practice Address - Country:US
Practice Address - Phone:314-325-8925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8H68207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1154348761Medicare UPIN