Provider Demographics
NPI:1548259518
Name:GALLAGHER, DAVID LAWRENCE (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:GALLAGHER
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 1:1401 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1367
Mailing Address - Country:US
Mailing Address - Phone:209-527-6640
Mailing Address - Fax:209-527-5489
Practice Address - Street 1:1401 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1367
Practice Address - Country:US
Practice Address - Phone:209-527-6640
Practice Address - Fax:209-527-5489
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6031152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10207Medicare UPIN
CA1067170001Medicare NSC