Provider Demographics
NPI:1538275961
Name:MCGANNON, MARK C (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:MCGANNON
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:PO BOX 1226
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1226
Mailing Address - Country:US
Mailing Address - Phone:803-534-0226
Mailing Address - Fax:
Practice Address - Street 1:1190 SUMMERS AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4922
Practice Address - Country:US
Practice Address - Phone:803-534-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8845207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC088452Medicaid
SCB92406Medicare UPIN