Provider Demographics
NPI:1275560286
Name:GANNON, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:545 E CLEVELAND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5535
Mailing Address - Country:US
Mailing Address - Phone:209-948-0205
Mailing Address - Fax:209-948-0245
Practice Address - Street 1:545 E CLEVELAND ST
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5535
Practice Address - Country:US
Practice Address - Phone:209-948-0205
Practice Address - Fax:209-948-0245
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25472174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42678Medicare UPIN