Provider Demographics
NPI:1962409128
Name:CONCANNON, JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:CONCANNON
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 1:1145 RESERVOIR AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6055
Mailing Address - Country:US
Mailing Address - Phone:401-943-7337
Mailing Address - Fax:401-942-1509
Practice Address - Street 1:1145 RESERVOIR AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6055
Practice Address - Country:US
Practice Address - Phone:401-943-7337
Practice Address - Fax:401-942-1509
Is Sole Proprietor?:No
Enumeration Date:2005-07-02
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-25
Provider Licenses
StateLicense IDTaxonomies
RIDO-00357208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIC90437Medicare UPIN