Provider Demographics
NPI:1083676852
Name:GANNON, TIMOTHY HUGH (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:HUGH
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 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-4788
Mailing Address - Fax:334-793-1561
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 403
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-4788
Practice Address - Fax:334-793-1561
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL174017500OtherUS DEPT OF LAOBR
AL000031973Medicaid
AL000031973Medicaid
AL174017500OtherUS DEPT OF LAOBR