Provider Demographics
NPI:1043256787
Name:GALLAGHER, KIMBERLY MAZZEI (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MAZZEI
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:800-456-4629
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:35141 ATLANTIC AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:DE
Practice Address - Zip Code:19967-6954
Practice Address - Country:US
Practice Address - Phone:302-537-3740
Practice Address - Fax:302-537-3744
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001130401Medicaid
DE0001130401Medicaid
G86124Medicare UPIN