Provider Demographics
NPI:1356309942
Name:GANNON, HERBERT H JR (MD)
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:H
Last Name:GANNON
Suffix:JR
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 WEST MAIN STREET
Mailing Address - Street 2:STE 31
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4300
Mailing Address - Country:US
Mailing Address - Phone:334-793-6511
Mailing Address - Fax:334-677-5642
Practice Address - Street 1:4300 WEST MAIN STREET
Practice Address - Street 2:SUITE 31 WOMENS HEALTHCARE OF DOTHAN PC
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4300
Practice Address - Country:US
Practice Address - Phone:334-793-6511
Practice Address - Fax:334-677-5642
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006291207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000004270Medicaid
C74758Medicare UPIN
AL04270Medicare ID - Type Unspecified