Provider Demographics
NPI:1679730758
Name:MCGANNON, PETER M (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:MCGANNON
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 1:5001 ROCKSIDE RD # IN4
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2172
Mailing Address - Country:US
Mailing Address - Phone:216-986-4000
Mailing Address - Fax:
Practice Address - Street 1:5001 ROCKSIDE RD # IN4
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2172
Practice Address - Country:US
Practice Address - Phone:216-986-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-17
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3173207W00000X
OH35.095387207WX0120X, 207W00000X
IL125-049375207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3071287Medicaid