Healthcare Provider Details

I. General information

NPI: 1376291252
Provider Name (Legal Business Name): PATRICK JACOB GALLUCCI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

IV. Provider business mailing address

9040 JACKSON AVENUE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 762-408-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101279566
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: