Provider Demographics
NPI:1124197793
Name:GALLAGHER, JESSICA D (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
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 1:100 CROWNE POINT PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-5427
Mailing Address - Country:US
Mailing Address - Phone:513-743-7628
Mailing Address - Fax:513-737-1107
Practice Address - Street 1:302 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5037
Practice Address - Country:US
Practice Address - Phone:937-281-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2247401Medicaid
OHP00432941OtherRAILROAD MEDICARE
OH000000387041OtherANTHEM
OH000000387041OtherANTHEM
OH4049454Medicare PIN
OHH36243Medicare UPIN