Healthcare Provider Details

I. General information

NPI: 1366481129
Provider Name (Legal Business Name): GERALDINE GANNON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

3255 E ELWOOD ST #110
PHOENIX AZ
85034-7256
US

V. Phone/Fax

Practice location:
  • Phone: 602-470-5043
  • Fax: 602-470-5064
Mailing address:
  • Phone: 602-470-5043
  • Fax: 602-470-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number20335
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: