Provider Demographics
NPI:1316987217
Name:GALLAGHER, JOHN RYAN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RYAN
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1307
Mailing Address - Country:US
Mailing Address - Phone:580-379-9090
Mailing Address - Fax:580-379-9091
Practice Address - Street 1:3216 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1307
Practice Address - Country:US
Practice Address - Phone:580-379-9090
Practice Address - Fax:580-379-9091
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22340207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089670AMedicaid