Provider Demographics
NPI:1568573079
Name:GALLAGHER, JAMIE (OD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 SUWANEE DAM RD.
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:770-614-8577
Mailing Address - Fax:770-614-8509
Practice Address - Street 1:424 DECATUR ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1848
Practice Address - Country:US
Practice Address - Phone:678-843-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002162152W00000X
GAGA0002162152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U60432Medicare UPIN