Provider Demographics
NPI:1639501513
Name:DAVID GANNON, DPM, LLC
Entity Type:Organization
Organization Name:DAVID GANNON, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-629-0222
Mailing Address - Street 1:9956 N MAIN ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1077
Mailing Address - Country:US
Mailing Address - Phone:410-629-0222
Mailing Address - Fax:410-629-0225
Practice Address - Street 1:96 ATLANTIC AVE
Practice Address - Street 2:UNIT #3
Practice Address - City:OCEAN VIEW
Practice Address - State:DE
Practice Address - Zip Code:19970-9103
Practice Address - Country:US
Practice Address - Phone:410-629-0222
Practice Address - Fax:410-629-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE1-0000205213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEE1-0000205OtherDELAWARE LICENSE
DE1861415200Medicaid