Provider Demographics
NPI:1881749018
Name:GANNON, RICHARD W (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:GANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 F48 WEST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208
Mailing Address - Country:US
Mailing Address - Phone:641-792-4385
Mailing Address - Fax:
Practice Address - Street 1:800 S FILLMORE ST
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IA
Practice Address - Zip Code:50213-1619
Practice Address - Country:US
Practice Address - Phone:641-342-2184
Practice Address - Fax:800-305-3233
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02001207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A02302Medicare UPIN