=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861415200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID GANNON DPM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 11/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9956 N MAIN ST SUITE #5
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-629-0222
-----------------------------------------------------
Fax | 410-629-0225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9956 N MAIN ST SUITE #5
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-629-0222
-----------------------------------------------------
Fax | 410-629-0225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST/SOLE OWNER
-----------------------------------------------------
Name | DR. DAVID GANNON
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 410-629-0222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 01311
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------