Provider Demographics
NPI:1992700256
Name:GANNON, JOE M (MD)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:M
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 1:124 KAROLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3505
Mailing Address - Country:US
Mailing Address - Phone:225-718-3764
Mailing Address - Fax:
Practice Address - Street 1:607 RUE DE BRILLE
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2169
Practice Address - Country:US
Practice Address - Phone:337-367-1247
Practice Address - Fax:337-365-7496
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10553R207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1655091Medicaid
LA5W030CG22Medicare ID - Type Unspecified
LAG01459Medicare UPIN