Provider Demographics
NPI:1770668311
Name:GALLAGHER, JASON R (M D)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 COLLEGE AVE
Mailing Address - Street 2:STE G-210
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2770
Mailing Address - Country:US
Mailing Address - Phone:785-537-9030
Mailing Address - Fax:785-537-3334
Practice Address - Street 1:1133 COLLEGE AVE
Practice Address - Street 2:STE G-210
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2770
Practice Address - Country:US
Practice Address - Phone:785-537-9030
Practice Address - Fax:785-537-3334
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04 286812080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100367180AMedicaid
KS058515OtherBLUE SHIELD