Provider Demographics
NPI:1609402544
Name:GALLIMORE, JONATHAN TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:TYLER
Last Name:GALLIMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-5331
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1100 REID PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-983-3492
Practice Address - Fax:765-983-7958
Is Sole Proprietor?:No
Enumeration Date:2020-03-22
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL84344207Q00000X
IN01090085A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine