Provider Demographics
NPI:1457452237
Name:GALLAWAY, MICHAEL F
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:GALLAWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 W LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8104
Mailing Address - Country:US
Mailing Address - Phone:856-797-7922
Mailing Address - Fax:
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001315152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABLUE SHIELDOther186014
PA2248OtherHMO
PA2248OtherHMO
PA168562Medicare ID - Type Unspecified