Provider Demographics
NPI:1619992690
Name:GANNON, JASON (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GANNON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SAFRAN AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3205
Mailing Address - Country:US
Mailing Address - Phone:973-818-9104
Mailing Address - Fax:
Practice Address - Street 1:111 MULBERRY ST
Practice Address - Street 2:SUITE 1R
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4008
Practice Address - Country:US
Practice Address - Phone:973-818-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00257500213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8238502Medicaid
NJU81534Medicare UPIN
NJ041359Medicare ID - Type Unspecified