Healthcare Provider Details

I. General information

NPI: 1770624371
Provider Name (Legal Business Name): GARY LYLE GALLAGHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SW MILL VIEW WAY STE 250
BEND OR
97702-1140
US

IV. Provider business mailing address

2249 NW LAKESIDE PL
BEND OR
97703-1354
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-3184
  • Fax:
Mailing address:
  • Phone: 541-728-3184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD21961
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier134297
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: