Provider Demographics
NPI:1215900717
Name:CANNON, RAYMOND JOE (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JOE
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R.
Other - Middle Name:JOE
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD,
Mailing Address - Street 1:7110 WYOMING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4867
Mailing Address - Country:US
Mailing Address - Phone:505-346-0500
Mailing Address - Fax:
Practice Address - Street 1:7110 WYOMING BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4867
Practice Address - Country:US
Practice Address - Phone:505-346-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM70-23207W00000X
CO33672207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME29294Medicare UPIN
NM343432400Medicare PIN
NM343432400Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID