Provider Demographics
NPI:1841286424
Name:GANNON, MARC JAY (OD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:JAY
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 1:2021 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE #301
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3763
Mailing Address - Country:US
Mailing Address - Phone:954-776-5223
Mailing Address - Fax:954-491-0027
Practice Address - Street 1:2021 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE #301
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3763
Practice Address - Country:US
Practice Address - Phone:954-776-5223
Practice Address - Fax:954-491-0027
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2007-11-27
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-18
Provider Licenses
StateLicense IDTaxonomies
FLOPC001271152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84099Medicare UPIN
FL19374BMedicare ID - Type Unspecified