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General NPI Number Information
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NPI Number | 1194974782
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Entity Type | Organization
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Legal Business Name | MARC JAY GANNON OPTOMETRIST PA
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Dates
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Enumeration Date | 09/18/2008
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Last Update Date | 08/04/2009
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Provider Practice Location Address
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Address Line | 2021 E COMMERCIAL BLVD 301
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-3763
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Country | US
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Telephone | 954-776-5223
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Fax | 954-491-0027
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Provider Business Mailing Address
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Address Line | 2021 E COMMERCIAL BLVD 301
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-3763
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Country | US
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Telephone | 954-776-5223
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Fax | 954-491-0027
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. MARC JAY GANNON
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Credential | O.D.
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Telephone | 954-776-5223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WL0500X
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Taxonomy Name | Low Vision Rehabilitation Optometrist
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License Number | OPC1271
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License Number State | FL
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