Provider Demographics
NPI:1508952847
Name:GANNON, TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
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 1:9650 FRESH AIR DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-2088
Mailing Address - Country:US
Mailing Address - Phone:719-556-7804
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST BLDG 725
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-7804
Practice Address - Fax:719-556-7399
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350828732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000346010OtherANTHEM
OHH99903Medicare UPIN
OH4125564Medicare ID - Type Unspecified
OH4125561Medicare ID - Type Unspecified
OH4125563Medicare ID - Type Unspecified
OH4125562Medicare ID - Type Unspecified