Basic Information
| Provider Information | |||||||||
| NPI: | 1831145259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAGNON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 ROUTE 108 | ||||||||
| Address2: | BUSINESS OFFICE | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CAMPUS DR STE 12 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038015892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034228208 | ||||||||
| FaxNumber: | 6034228218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/23/2011 | ||||||||
| NPIReactivationDate: | 10/23/2013 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12177 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7236 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30001207 | 05 | NH | MEDICAID | 239030099 | 05 | ME | MEDICAID |