Provider Demographics
NPI:1922066331
Name:GANNON, KATHLEEN RITA (DO)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:RITA
Last Name:GANNON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6800 LAKE DRIVE
Mailing Address - Street 2:STE 250
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-2504
Mailing Address - Country:US
Mailing Address - Phone:515-875-9925
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:1810 SW WHITE BIRCH CIRCLE
Practice Address - Street 2:STE 111
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7226
Practice Address - Country:US
Practice Address - Phone:515-964-7115
Practice Address - Fax:515-964-7899
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-07-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ART2006-010207R00000X
IA03077207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159949003Medicaid
IA9170589Medicaid
AR5N503Medicare ID - Type Unspecified
G69353Medicare UPIN
AR159949003Medicaid