Provider Demographics
NPI:1477554061
Name:GALLAGHER, MINDY L (DO)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:L
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PARK PLACE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007
Mailing Address - Country:US
Mailing Address - Phone:212-226-7666
Mailing Address - Fax:212-202-7988
Practice Address - Street 1:15 WARREN ST.
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007
Practice Address - Country:US
Practice Address - Phone:212-226-7666
Practice Address - Fax:212-202-7988
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225141208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02361008Medicaid
NYH85955Medicare UPIN
NY02361008Medicaid