Provider Demographics
NPI:1215094040
Name:GALLAGHER, PATRICK TIMOTHY SR (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:TIMOTHY
Last Name:GALLAGHER
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2049 PEPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-9412
Mailing Address - Country:US
Mailing Address - Phone:318-798-7077
Mailing Address - Fax:318-798-7077
Practice Address - Street 1:2510 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3119
Practice Address - Country:US
Practice Address - Phone:318-212-5500
Practice Address - Fax:318-212-5358
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.016829207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA016829OtherSTATE LICENSE
LA1344231Medicaid
LA016829OtherSTATE LICENSE
LAB63399Medicare UPIN