Provider Demographics
NPI:1699740456
Name:GALLAGHER, GARY (OD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1449
Mailing Address - Country:US
Mailing Address - Phone:530-222-3166
Mailing Address - Fax:530-222-6539
Practice Address - Street 1:3080 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1449
Practice Address - Country:US
Practice Address - Phone:530-222-3166
Practice Address - Fax:530-222-6539
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6443T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA408836OtherMEDICARE GROUP PTAN
CASD0064430Medicaid
CA1699740456OtherINDIVIDUAL NPI
CACA412404OtherINDIVIDUAL MEDICARE PTAN
CAZZZ27139ZOtherMEDICARE LEGACY GROUP NUMBER
CA1699740456OtherINDIVIDUAL NPI
CASD0064430OtherMEDICARE, LEGACY NUMBER