Provider Demographics
NPI:1104964808
Name:GALLAGHER, GARY DAVID (DPM)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DAVID
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:DAVID
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:3550 HOBSON RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1434
Mailing Address - Country:US
Mailing Address - Phone:630-971-3338
Mailing Address - Fax:630-971-3954
Practice Address - Street 1:3550 HOBSON RD
Practice Address - Street 2:SUITE 204
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1434
Practice Address - Country:US
Practice Address - Phone:630-971-3338
Practice Address - Fax:630-971-3954
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003524213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0984470001Medicare NSC