Provider Demographics
NPI:1902894017
Name:CANNON, NEIL F (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:F
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-335-8885
Mailing Address - Fax:
Practice Address - Street 1:11 MAYO DR
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-1539
Practice Address - Country:US
Practice Address - Phone:508-829-4355
Practice Address - Fax:508-829-9119
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110036781AMedicaid
MAE21018Medicare ID - Type Unspecified
MA110036781AMedicaid