1841286424 NPI number — DR. MARC JAY GANNON O.D.

Table of content: DR. MARC JAY GANNON O.D. (NPI 1841286424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841286424 NPI number — DR. MARC JAY GANNON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANNON
Provider First Name:
MARC
Provider Middle Name:
JAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841286424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/24/2006
NPI Reactivation Date:
04/18/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 E COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE #301
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-776-5223
Provider Business Mailing Address Fax Number:
954-491-0027

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 E COMMERCIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE #301
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-776-5223
Provider Business Practice Location Address Fax Number:
954-491-0027
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WL0500X , with the licence number:  OPC001271 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113210100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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