Provider Demographics
NPI:1396718201
Name:BANNON, JOHN DAVID (MD,FACS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:BANNON
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:DAVID
Other - Last Name:BANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD,FACS
Mailing Address - Street 1:543 BAY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1441
Mailing Address - Country:US
Mailing Address - Phone:518-761-2663
Mailing Address - Fax:518-761-6831
Practice Address - Street 1:543 BAY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1441
Practice Address - Country:US
Practice Address - Phone:518-761-2663
Practice Address - Fax:518-761-6831
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00832751Medicaid
NY136663OtherLICENSE
NYBB1015088OtherDEA
NY8775677173Medicare ID - Type Unspecified
NYBB1015088OtherDEA