MEDICARE: DR. JOE M. 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	207W00000X	Ophthalmology Physician	10553R	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992700256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOE M. GANNON MD

Provider Business Mailing Address
First Line	:	124 KAROLWOOD DR
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70503-3505
Country	:	US
Telephone Number	:	225-718-3764
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 RUE DE BRILLE
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70563-2169
Country	:	US
Telephone Number	:	337-367-1247
Fax Number	:	337-365-7496

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

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	05/12/2021

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