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Individual

DR. CHARLES LAWRENCE CANNON

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
M.D.

Contact information

Practice address
1218 W WILLOW, STE A, ENID, OK 73703-2534
(580) 233-2176
(580) 233-2179
Mailing address
1218 W WILLOW RD, STE A, ENID, OK 73703-2534
(580) 233-2176
(580) 233-2179

Taxonomy

Speciality
Code
Description
License number
State
207RG0100X
Gastroenterology Physician
Primary
17275
OK

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
0000
TRICARE REGION 6
OK
01
100007598
RAILROAD MEDICARE
GA
05
100088540A
OK
Enumeration date
06/27/2005
Last updated
12/11/2012
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