Provider Demographics
NPI:1861415200
Name:DAVID GANNON DPM LLC
Entity type:Organization
Organization Name:DAVID GANNON DPM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-629-0222
Mailing Address - Street 1:9956 N MAIN ST
Mailing Address - Street 2:SUITE #5
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1077
Mailing Address - Country:US
Mailing Address - Phone:410-629-0222
Mailing Address - Fax:410-629-0225
Practice Address - Street 1:9956 N MAIN ST
Practice Address - Street 2:SUITE #5
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1077
Practice Address - Country:US
Practice Address - Phone:410-629-0222
Practice Address - Fax:410-629-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01311213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4150953-00Medicaid
MDDN7994OtherRAIL ROAD MEDICARE GROUP PTAN
6031730001OtherDME
MDDN7994OtherRAIL ROAD MEDICARE GROUP PTAN
MDU81449Medicare UPIN
MD518PMedicare PIN