Basic Information
| Provider Information | |||||||||
| NPI: | 1508952847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9650 FRESH AIR DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809242088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195567804 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 559 VINCENT ST BLDG 725 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195567804 | ||||||||
| FaxNumber: | 7195567399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35082873 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000000346010 | 01 | OH | ANTHEM | OTHER |