Provider Demographics
NPI:1043301831
Name:GALLAGHER, JOHN J (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4320 SUWANEE DAM RD
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:770-614-8577
Mailing Address - Fax:770-614-8509
Practice Address - Street 1:4320 SUWANEE DAM RD.
Practice Address - Street 2:SUITE 2100
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024
Practice Address - Country:US
Practice Address - Phone:770-614-8577
Practice Address - Fax:770-614-8509
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA2163152W00000X
GAGA0002163152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U60431Medicare UPIN
460431Medicare UPIN
41ZCFQFMedicare ID - Type Unspecified