Provider Demographics
NPI:1780618983
Name:J. DAVID BANNON MD PC
Entity type:Organization
Organization Name:J. DAVID BANNON MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-761-2663
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:518-761-2663
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136663174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00832751Medicaid
NY00832751Medicaid
NYB80890Medicare UPIN