Healthcare Provider Details

I. General information

NPI: 1902394752
Provider Name (Legal Business Name): JACOB RYAN GALLAGHER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 03/10/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MILL RIVER STREET SUITE 2400-C
STAMFORD CT
06902
US

IV. Provider business mailing address

80 MILL RIVER STREET SUITE 2400-C
STAMFORD CT
06902
US

V. Phone/Fax

Practice location:
  • Phone: 203-585-9580
  • Fax:
Mailing address:
  • Phone: 203-585-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number69540
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: