Active NPI
Charles Lawrence Cannon, M.D.
- Gastroenterology Physician
- Enid, OK
National Provider Identifier
1073519815
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Gastroenterology Physician
- License
- 17275
- Practice address
- 1218 W Willow
Ste a
Enid, OK 73703-2534 - Phone
- (580) 233-2176
- Fax
- (580) 233-2179
- NPI assigned
- Jun 27, 2005
- Reactivated
- Mar 27, 2006
- Last updated
- Dec 11, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Gastroenterology Physician | 207RG0100X | 17275 | OK | Primary |
Addresses
Primary practice location
1218 W Willow
Ste a
Enid, OK 73703-2534
Mailing address
1218 W Willow Rd
Ste a
Enid, OK 73703-2534
Phone (580) 233-2176
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0000 | Other | OK | TRICARE REGION 6 |
| 100007598 | Other | GA | RAILROAD MEDICARE |
| 100088540A | Medicaid | OK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1119830400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1355184000000",
"number": "1073519815",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1218 W WILLOW RD",
"address_2": "STE A",
"city": "ENID",
"state": "OK",
"postal_code": "737032534",
"telephone_number": "580-233-2176",
"fax_number": "580-233-2179"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1218 W WILLOW",
"address_2": "STE A",
"city": "ENID",
"state": "OK",
"postal_code": "737032534",
"telephone_number": "580-233-2176",
"fax_number": "580-233-2179"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CANNON",
"first_name": "CHARLES",
"middle_name": "LAWRENCE",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-06-27",
"last_updated": "2012-12-11",
"deactivation_date": "2006-03-17",
"reactivation_date": "2006-03-27",
"status": "A"
},
"taxonomies": [
{
"code": "207RG0100X",
"taxonomy_group": "",
"desc": "Internal Medicine, Gastroenterology",
"state": "OK",
"license": "17275",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TRICARE REGION 6",
"identifier": "0000",
"state": "OK"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "100007598",
"state": "GA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100088540A",
"state": "OK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Enid, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 11, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.