Provider Demographics
NPI:1114084274
Name:GALLY, JEFFREY PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:GALLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 COCONUT CREEK PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-1652
Mailing Address - Country:US
Mailing Address - Phone:954-971-6188
Mailing Address - Fax:954-970-4944
Practice Address - Street 1:3880 COCONUT CREEK PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-1652
Practice Address - Country:US
Practice Address - Phone:954-971-6188
Practice Address - Fax:954-970-4944
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11837Medicare ID - Type Unspecified
FLE84533Medicare UPIN