Provider Demographics
NPI:1376521492
Name:GANNON, DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GANNON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:9956 N MAIN ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1077
Mailing Address - Country:US
Mailing Address - Phone:410-629-0222
Mailing Address - Fax:410-629-0225
Practice Address - Street 1:9956 N MAIN ST
Practice Address - Street 2:SUITE #5
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1077
Practice Address - Country:US
Practice Address - Phone:410-629-0222
Practice Address - Fax:410-629-0225
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEE1-0000205213E00000X
MD01311213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEE1-0000205OtherSTATE LICENSE
MD3494004-00Medicaid
DE6031730002OtherDME
MDP00639639OtherRAIL ROAD MEDICARE - INDIVIDUAL PTAN
MDP00639639OtherRAIL ROAD MEDICARE - INDIVIDUAL PTAN
DE6031730002OtherDME