Basic Information
Provider Information
NPI: 1003012733
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GANNON
FirstName: LAUREN
MiddleName: C.
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: WORTH
OtherFirstName: LAUREN
OtherMiddleName: C.
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MD
OtherLastNameType: 1
Mailing Information
Address1: 823 GATEWAY CENTER WAY
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921024541
CountryCode: US
TelephoneNumber: 6195152300
FaxNumber: 6199064623
Practice Location
Address1: 5454 EL CAJON BLVD.
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 92115
CountryCode: US
TelephoneNumber: 6195152400
FaxNumber: 6195469900
Other Information
ProviderEnumerationDate: 06/21/2007
LastUpdateDate: 10/14/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XA105771CAY Allopathic & Osteopathic PhysiciansInternal Medicine 
208000000XA105771CAN Allopathic & Osteopathic PhysiciansPediatrics 

No ID Information.


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