Healthcare Provider Details

I. General information

NPI: 1184640138
Provider Name (Legal Business Name): DAVID THOMAS HANNAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3669 COUNTRYSIDE LN
MARION NY
14505-9781
US

IV. Provider business mailing address

3669 COUNTRYSIDE LN PO BOX 110
MARION NY
14505-9781
US

V. Phone/Fax

Practice location:
  • Phone: 315-926-7733
  • Fax: 315-926-0731
Mailing address:
  • Phone: 315-926-7733
  • Fax: 315-926-0731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number156845
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: