Provider Demographics
NPI:1528097045
Name:CANNON, ROBERT JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAMES
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 1:11 STONEGATE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2451
Mailing Address - Country:US
Mailing Address - Phone:949-734-3363
Mailing Address - Fax:949-294-1404
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:951-352-5666
Practice Address - Fax:951-352-5445
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39500207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A395000Medicaid
CA00A395000Medicaid
CA00A395001Medicare PIN
CAWA39500MMedicare PIN
CABT092YMedicare PIN
CAP00797425Medicare PIN
CABT092ZMedicare PIN