Provider Demographics
NPI:1043615180
Name:WILLIAM R. GALLIVAN, JR., M.D., INC.
Entity Type:Organization
Organization Name:WILLIAM R. GALLIVAN, JR., M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:GALLIVAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:805-220-6020
Mailing Address - Street 1:320 W JUNIPERO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4305
Mailing Address - Country:US
Mailing Address - Phone:805-220-6020
Mailing Address - Fax:805-284-0085
Practice Address - Street 1:320 W JUNIPERO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4305
Practice Address - Country:US
Practice Address - Phone:805-220-6020
Practice Address - Fax:805-284-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207X00000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB224471Medicare PIN
CA00G739010Medicaid
CAG73901OtherMEDICAL LICENSE