Provider Demographics
NPI:1366825234
Name:GALLAGHER, MARIAM (DO)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2055 KIMBALL AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5047
Mailing Address - Country:US
Mailing Address - Phone:818-624-4536
Mailing Address - Fax:
Practice Address - Street 1:2055 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5014
Practice Address - Country:US
Practice Address - Phone:818-624-4536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS6840207Q00000X
OK5940207Q00000X
OK0097R207Q00000X
IADO-05933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine