Provider Demographics
NPI:1184640138
Name:HANNAN, DAVID THOMAS (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:HANNAN
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 1:3669 COUNTRYSIDE LN
Mailing Address - Street 2:PO BOX 110
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-9781
Mailing Address - Country:US
Mailing Address - Phone:315-926-7733
Mailing Address - Fax:315-926-0731
Practice Address - Street 1:3669 COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NY
Practice Address - Zip Code:14505-9781
Practice Address - Country:US
Practice Address - Phone:315-926-7733
Practice Address - Fax:315-926-0731
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010156845OtherBLUE CHOICE
NY01389073Medicaid
NYMD109BOtherPREFERRED CARE
NYMD109BOtherPREFERRED CARE
NY01389073Medicaid