Provider Demographics
NPI:1114034808
Name:GALLAHER, KATHLEEN EMILIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:EMILIE
Last Name:GALLAHER
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 1:17871 SANTIAGO BLVD
Mailing Address - Street 2:SUITE 206 FIRST FLOOR
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92861-4141
Mailing Address - Country:US
Mailing Address - Phone:714-974-1362
Mailing Address - Fax:714-974-3145
Practice Address - Street 1:17871 SANTIAGO BLVD
Practice Address - Street 2:SUITE 206 FIRST FLOOR
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92861-4141
Practice Address - Country:US
Practice Address - Phone:714-974-1362
Practice Address - Fax:714-974-3145
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00004108OtherRAILROAD MEDICARE
05D1010073OtherCLIA
05D1010073OtherCLIA
AG2636910OtherDEA
W15972Medicare ID - Type Unspecified