Provider Demographics
NPI:1760478226
Name:GANNON, JULIA H (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIA
Middle Name:H
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 1:1201 11TH AVE S
Mailing Address - Street 2:SUITE 501
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-3423
Mailing Address - Country:US
Mailing Address - Phone:205-930-0930
Mailing Address - Fax:205-930-9050
Practice Address - Street 1:1201 11TH AVE S
Practice Address - Street 2:SUITE 501
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-3423
Practice Address - Country:US
Practice Address - Phone:205-930-0930
Practice Address - Fax:205-930-9050
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS708TA316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528500580Medicaid
AL51502838OtherBCBS
AL528500580Medicaid
AL1063421261Medicare NSC
AL51502838OtherBCBS
0766130001Medicare NSC
AL1780751040Medicare NSC
U06204Medicare UPIN