Provider Demographics
NPI:1619594470
Name:GALLEN, QUINN (OD)
Entity Type:Individual
Prefix:
First Name:QUINN
Middle Name:
Last Name:GALLEN
Suffix:
Gender:M
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:PO BOX 207158
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7158
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:84 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2822
Practice Address - Country:US
Practice Address - Phone:901-832-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-28
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015615152W00000X, 152WX0102X
IL046.011449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision