Provider Demographics
NPI:1043264930
Name:GANNON, PATRICK LAWRENCE (OD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:LAWRENCE
Last Name:GANNON
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 1:7205 MILLS CIVIC PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8140
Mailing Address - Country:US
Mailing Address - Phone:515-222-2924
Mailing Address - Fax:
Practice Address - Street 1:7205 MILLS CIVIC PKWY
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8140
Practice Address - Country:US
Practice Address - Phone:515-222-2924
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAU97364Medicare UPIN
IAI10757Medicare ID - Type Unspecified