Provider Demographics
NPI:1720151566
Name:GALLAGHER, JOHN (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 CAPISIC ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1741
Mailing Address - Country:US
Mailing Address - Phone:207-772-2311
Mailing Address - Fax:207-772-2419
Practice Address - Street 1:520 CAPISIC ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1741
Practice Address - Country:US
Practice Address - Phone:207-772-2311
Practice Address - Fax:207-772-2419
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME023203OtherANTHEM
MET31356Medicare UPIN
MEGA MM0744Medicare ID - Type Unspecified