Healthcare Provider Details

I. General information

NPI: 1932603776
Provider Name (Legal Business Name): EIAN GALLAGHER PROHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16111 PLUMMER ST
NORTH HILLS CA
91343-2036
US

IV. Provider business mailing address

16111 PLUMMER ST
NORTH HILLS CA
91343-2036
US

V. Phone/Fax

Practice location:
  • Phone: 818-891-7711
  • Fax: 904-406-7123
Mailing address:
  • Phone: 818-891-7711
  • Fax: 904-406-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA164887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: