Provider Demographics
NPI:1053303024
Name:GANNON, CHARLES SANFORD (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:SANFORD
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 1:1645 N. ALVERNON WAY #1
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-3353
Mailing Address - Country:US
Mailing Address - Phone:520-881-7474
Mailing Address - Fax:520-881-0676
Practice Address - Street 1:1645 N. ALVERNON WAY #1
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-881-7474
Practice Address - Fax:520-881-0676
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6156207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ221193Medicaid
AZC99509Medicare UPIN
AZ221193Medicaid