Provider Demographics
NPI:1619965696
Name:BANNON, MICHAEL GRIDLEY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRIDLEY
Last Name:BANNON
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:PO BOX 840853
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75284-0853
Practice Address - Country:US
Practice Address - Phone:214-696-3540
Practice Address - Fax:214-696-1230
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5796207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000963D9Medicaid
TXE47013Medicare UPIN
TXP000963D9Medicaid