Individual
JASON GANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.P.M.
Contact information
Practice address
111 MULBERRY ST, SUITE 1R, NEWARK, NJ 07102-4008
(973) 818-9104
Mailing address
131 SAFRAN AVE, EDISON, NJ 08837-3205
(973) 818-9104
Taxonomy
Speciality
Code
Description
License number
State
213ES0131X
Foot Surgery Podiatrist
Primary
25MD00257500
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8238502
—
NJ
Enumeration date
07/12/2006
Last updated
12/22/2010
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