Provider Demographics
NPI:1205837234
Name:GALLAHER, JOHN R (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GALLAHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MAIN ST
Mailing Address - Street 2:STE 102
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3584
Mailing Address - Country:US
Mailing Address - Phone:615-444-9111
Mailing Address - Fax:615-444-1040
Practice Address - Street 1:401 W MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3555
Practice Address - Country:US
Practice Address - Phone:615-444-9111
Practice Address - Fax:615-444-1040
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT1493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3599128Medicaid
TN261354605OtherDEFAULT
TN4165732OtherBCBS
TN3599128Medicare ID - Type Unspecified