1407162936 NPI number — DR. MARK J CANNON OD

Table of content: MS. LYNN YVETTE JONES LPN (NPI 1083929343)

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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