Basic Information
| Provider Information | |||||||||
| NPI: | 1437269479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | RON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5345 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019325244 | ||||||||
| FaxNumber: | 6019390545 | ||||||||
| Practice Location | |||||||||
| Address1: | 1038 RIVER OAKS DR | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019325244 | ||||||||
| FaxNumber: | 6019390545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | 07635 | MS | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 08553384 | 05 | MS | MEDICAID |