Provider Demographics
NPI:1235181207
Name:GALLOWAY, JACQULYN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQULYN
Middle Name:
Last Name:GALLOWAY
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 1:11783 ROCK LANDING DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4431
Mailing Address - Country:US
Mailing Address - Phone:757-668-6300
Mailing Address - Fax:757-668-6310
Practice Address - Street 1:11783 ROCK LANDING DR
Practice Address - Street 2:SUITE 202
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4431
Practice Address - Country:US
Practice Address - Phone:757-668-6300
Practice Address - Fax:757-668-6310
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053437208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541778786OtherTAX ID #
VA56204OtherSENTARA OPTIMA
VA6728791Medicaid
VA859093OtherOPTIMUM
VA4121007OtherAETNA
VA015100OtherANTHEM
VA600101779OtherCIGNA
VA541778786OtherTRICARE
VA859093OtherMAMSI
VA6728791Medicaid