Individual
DR. OCTAVIA MANETTA CANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
1560 TURF LN, EAST LANSING, MI 48823-6392
(517) 484-3000
Mailing address
1560 TURF LN, EAST LANSING, MI 48823-6392
(517) 484-3000
(517) 484-6358
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
9900020
NC
207V00000X
Obstetrics & Gynecology Physician
Primary
5101012864
MI
207V00000X
Obstetrics & Gynecology Physician
99-00020
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5101012864
MICHIGAN PHYSICIAN LICENSE
MI
05
—
891197H
—
NC
Enumeration date
01/13/2006
Last updated
09/02/2021
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