Provider Demographics
NPI:1831145259
Name:GAGNON, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:GAGNON
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 1:311 ROUTE 108
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:SOMERSWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03878-1522
Mailing Address - Country:US
Mailing Address - Phone:603-749-2346
Mailing Address - Fax:603-953-0066
Practice Address - Street 1:100 CAMPUS DR STE 12
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5892
Practice Address - Country:US
Practice Address - Phone:603-422-8208
Practice Address - Fax:603-422-8218
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-08-18
Deactivation Date:2011-09-23
Deactivation Code:
Reactivation Date:2013-10-23
Provider Licenses
StateLicense IDTaxonomies
ME12177207Q00000X
NH7236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30001207Medicaid
ME239030099Medicaid
ME239030099Medicaid
NH30001207Medicaid