Provider Demographics
NPI:1003817404
Name:GALL, CLIFFORD M (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:M
Last Name:GALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2609 GLENN HENDREN DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3313
Mailing Address - Country:US
Mailing Address - Phone:816-781-7730
Mailing Address - Fax:
Practice Address - Street 1:2521 GLENN HENDREN DR STE 108
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-3388
Practice Address - Country:US
Practice Address - Phone:816-781-3515
Practice Address - Fax:816-781-3517
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04 23541207T00000X
MOMD R4P55207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO17554034OtherBCBS
E87101Medicare UPIN