Provider Demographics
NPI:1821090184
Name:BANNON, JOSEPH M (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:BANNON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 GREENTREE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-1443
Mailing Address - Country:US
Mailing Address - Phone:740-695-0526
Mailing Address - Fax:740-695-5209
Practice Address - Street 1:1021 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5779
Practice Address - Country:US
Practice Address - Phone:304-234-4455
Practice Address - Fax:304-234-4452
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV797-OD152W00000X
OH3766152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH410045918OtherMEDICARE RAILROAD
OH410045918OtherMEDICARE RAILROAD
OH4244031Medicare PIN