MEDICARE: DR. CYNTHIA GANNON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01042254A	IN

General Provider Information

NPI Number	:	1649366360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CYNTHIA GANNON MD

Provider Business Mailing Address
First Line	:	436 E WASHINGTON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-3210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	436 E WASHINGTON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46802-3210
Country	:	US
Telephone Number	:	260-264-7711
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	11/08/2024

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