Provider Demographics
NPI:1003886128
Name:GANNON, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:GANNON
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 1:2550 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5304
Mailing Address - Country:US
Mailing Address - Phone:309-793-4223
Mailing Address - Fax:309-793-6276
Practice Address - Street 1:2550 24TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5304
Practice Address - Country:US
Practice Address - Phone:309-793-4223
Practice Address - Fax:309-793-6276
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-053280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA98731OtherBLUE SHIELD
ILC43714Medicare UPIN
ILK45158Medicare PIN
IA98731OtherBLUE SHIELD