Provider Demographics
NPI:1891720587
Name:GAMMON, DAVID ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:GAMMON
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 1:3296 RIDGECANE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1078
Mailing Address - Country:US
Mailing Address - Phone:859-312-3377
Mailing Address - Fax:
Practice Address - Street 1:3296 RIDGECANE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1078
Practice Address - Country:US
Practice Address - Phone:859-312-3377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22708207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYASC1019OtherASC MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
KY110036800OtherRR MEDICARE PIN NO
KY64227085Medicaid
KYCB5773OtherRR MEDICARE GROUP
KY36000818OtherASC MEDICAID GROUP
KYCB5773OtherRR MEDICARE GROUP
KY4000501OtherMEDICARE LAB GROUP