1407162936 NPI number — DR. MARK J CANNON OD

Table of content: DR. MARK J CANNON OD (NPI 1407162936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407162936 NPI number — DR. MARK J CANNON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANNON
Provider First Name:
MARK
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407162936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2602 NE UNIVERSITY VILLAGE ST
Provider Second Line Business Mailing Address:
SUITE B (AT MARKET OPTICAL)
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98105-5023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-522-9323
Provider Business Mailing Address Fax Number:
206-525-3841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1906 PIKE PLACE, #8-B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98101-1055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-448-7739
Provider Business Practice Location Address Fax Number:
206-448-4924
Provider Enumeration Date:
08/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD60160060 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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