Healthcare Provider Details

I. General information

NPI: 1619996501
Provider Name (Legal Business Name): MARIE ELIZABETH GANNON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 GEHRINGER DR
FOWLERVILLE MI
48836-8622
US

IV. Provider business mailing address

PO BOX 463
BRIGHTON MI
48116-0463
US

V. Phone/Fax

Practice location:
  • Phone: 517-715-1002
  • Fax:
Mailing address:
  • Phone: 248-330-9478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003277
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: