Provider Demographics
NPI:1518966472
Name:GANNON, DAVID P JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
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 1:68 N MAIN ST STE A125
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MA
Mailing Address - Zip Code:02330-1128
Mailing Address - Country:US
Mailing Address - Phone:508-747-7246
Mailing Address - Fax:
Practice Address - Street 1:68 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARVER
Practice Address - State:MA
Practice Address - Zip Code:02330-1128
Practice Address - Country:US
Practice Address - Phone:508-747-7246
Practice Address - Fax:508-747-7256
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50303207R00000X, 208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA124352OtherHARVARD PILGRIM HEALTH CARE
MA3001091Medicaid
MAAA124352OtherHARVARD PILGRIM HEALTH CARE
B74536Medicare UPIN
MA3001091Medicaid