Provider Demographics
NPI:1902832769
Name:GANNON, WILLIAM J (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:GANNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 SPLIT ROCK DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1244
Mailing Address - Country:US
Mailing Address - Phone:856-424-9220
Mailing Address - Fax:
Practice Address - Street 1:2 SPLIT ROCK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-1244
Practice Address - Country:US
Practice Address - Phone:856-424-9220
Practice Address - Fax:856-424-5319
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ38MC00264900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ180600YAYTMedicare PIN