Provider Demographics
NPI:1639285356
Name:GALLAGHER, BRIAN J (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1921
Mailing Address - Country:US
Mailing Address - Phone:573-756-6751
Mailing Address - Fax:
Practice Address - Street 1:1103 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-756-6751
Practice Address - Fax:573-756-6807
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J312086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO247857105Medicaid
E78232Medicare UPIN
MO013012642Medicare ID - Type Unspecified