Provider Demographics
NPI:1194974782
Name:MARC JAY GANNON OPTOMETRIST PA
Entity type:Organization
Organization Name:MARC JAY GANNON OPTOMETRIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-776-5223
Mailing Address - Street 1:2021 E COMMERCIAL BLVD
Mailing Address - Street 2:301
Mailing Address - City:FORT 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 2:301
Practice Address - City:FORT 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1271152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078390100Medicaid
FL078390100Medicaid