Provider Demographics
NPI:1548419310
Name:GANNON, THOMAS MILTON (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MILTON
Last Name:GANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2339
Mailing Address - Country:US
Mailing Address - Phone:931-854-9393
Mailing Address - Fax:931-233-2449
Practice Address - Street 1:404 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501
Practice Address - Country:US
Practice Address - Phone:931-854-9393
Practice Address - Fax:931-233-2449
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1785208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509705Medicaid
TN1509705Medicaid