Provider Demographics
NPI:1609847292
Name:GALLANTER, TISHA (MD)
Entity Type:Individual
Prefix:DR
First Name:TISHA
Middle Name:
Last Name:GALLANTER
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 1:655 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-982-9586
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-5044
Practice Address - Fax:904-244-4508
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL194584146L00000X
FLME79093207P00000X
NY214121-1207P00000X
GA045065207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
930080642OtherRR CARE
GA00811885IMedicaid
GA000811885HMedicaid
FL256861600Medicaid
FLP00242437OtherRAILROAD MEDICARE
FL49209OtherBCBS
FLP00242437OtherRAILROAD MEDICARE
930080642OtherRR CARE
GA00811885IMedicaid
GA000811885HMedicaid
FLP00158354Medicare PIN