Healthcare Provider Details

I. General information

NPI: 1861571002
Provider Name (Legal Business Name): JOSEPH M. BANNON OD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 NATIONAL RD
WHEELING WV
26003-5779
US

IV. Provider business mailing address

1021 NATIONAL RD
WHEELING WV
26003-5779
US

V. Phone/Fax

Practice location:
  • Phone: 304-234-4455
  • Fax:
Mailing address:
  • Phone: 304-234-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3766
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number797D
License Number StateWV

VIII. Authorized Official

Name: JOSEPH M. BANNON
Title or Position: PRESIDENT
Credential: O.D.
Phone: 304-234-4455