Provider Demographics
NPI:1902394752
Name:GALLAGHER, JACOB RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RYAN
Last Name:GALLAGHER
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MILL RIVER STREET
Mailing Address - Street 2:SUITE 2400-C
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:203-585-9580
Mailing Address - Fax:
Practice Address - Street 1:80 MILL RIVER STREET
Practice Address - Street 2:SUITE 2400-C
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-585-9580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT69540204D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program