Healthcare Provider Details

I. General information

NPI: 1508952847
Provider Name (Legal Business Name): TIMOTHY GANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST BLDG 725
COLORADO SPRINGS CO
80914-1541
US

IV. Provider business mailing address

3020 EBBTIDE VW
COLORADO SPRINGS CO
80922-1272
US

V. Phone/Fax

Practice location:
  • Phone: 719-556-7804
  • Fax: 719-556-7399
Mailing address:
  • Phone: 719-493-2853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0063682
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: