Provider Demographics
NPI:1003133729
Name:HANNIBAL, JOHN JACOB IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:HANNIBAL
Suffix:IV
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 1:3348 WALLACE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1032
Mailing Address - Country:US
Mailing Address - Phone:716-773-1280
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-4226
Practice Address - Fax:716-898-3279
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program