Provider Demographics
NPI:1902095466
Name:CANNON, DEREK SLOANE (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:SLOANE
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12370 ROAD 505
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3364
Mailing Address - Country:US
Mailing Address - Phone:601-504-3170
Mailing Address - Fax:
Practice Address - Street 1:1530 US HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:AL
Practice Address - Zip Code:35594-5056
Practice Address - Country:US
Practice Address - Phone:205-487-7000
Practice Address - Fax:877-915-6502
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30358207P00000X
282N00000X
MS22691208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07877038Medicaid
AL9472Medicare PIN