=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699740456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY GALLAGHER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3080 VICTOR AVE
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96002-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-222-3166
-----------------------------------------------------
Fax | 530-222-6539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3080 VICTOR AVE
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96002-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-222-3166
-----------------------------------------------------
Fax | 530-222-6539
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6443T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------