Provider Demographics
NPI:1194086041
Name:GANNON, MICHAEL PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:GANNON
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:
Practice Address - Street 1:730 N BROAD ST STE 200A
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1796
Practice Address - Country:US
Practice Address - Phone:856-251-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251885207R00000X
PAMD466806207RC0000X
NJ25MA12053900207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine