Provider Demographics
NPI:1619996501
Name:GANNON, MARIE ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ELIZABETH
Last Name:GANNON
Suffix:
Gender:F
Credentials:OD
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 463
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-0463
Mailing Address - Country:US
Mailing Address - Phone:248-330-9478
Mailing Address - Fax:
Practice Address - Street 1:970 GEHRINGER DR
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836-8622
Practice Address - Country:US
Practice Address - Phone:517-715-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist