Provider Demographics
NPI:1134206634
Name:GANNON, ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:GANNON
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 1:1300 W JEFFERSON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-9120
Mailing Address - Country:US
Mailing Address - Phone:317-736-8474
Mailing Address - Fax:
Practice Address - Street 1:1300 W JEFFERSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-9120
Practice Address - Country:US
Practice Address - Phone:317-736-8474
Practice Address - Fax:317-736-6040
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100220010Medicaid
INB29382Medicare UPIN
080158794Medicare PIN
IN100220010Medicaid
IN151560KKKKMedicare PIN