Provider Demographics
NPI:1548255268
Name:GALLINGER, KENNETH D (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:GALLINGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 E SOUTHCROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-3636
Mailing Address - Country:US
Mailing Address - Phone:210-333-7777
Mailing Address - Fax:210-504-4377
Practice Address - Street 1:4045 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3636
Practice Address - Country:US
Practice Address - Phone:210-333-7777
Practice Address - Fax:210-504-4377
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02663T152W00000X, 152WV0400X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019183501Medicaid
TX019183501Medicaid
TX807766EMedicare PIN