Provider Demographics
NPI:1992770382
Name:GANNON, BARBARA V (MD)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:V
Last Name:GANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CORNELIA ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2779
Mailing Address - Country:US
Mailing Address - Phone:518-566-9452
Mailing Address - Fax:518-562-7189
Practice Address - Street 1:206 CORNELIA ST
Practice Address - Street 2:SUITE 306
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2779
Practice Address - Country:US
Practice Address - Phone:518-566-9452
Practice Address - Fax:518-562-7189
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236442174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02671112Medicaid
NYI45943Medicare UPIN
NY02671112Medicaid