Provider Demographics
NPI:1780661660
Name:GALLICK, MARYELLEN (OD)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:GALLICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 ECHELON MALL
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1943
Mailing Address - Country:US
Mailing Address - Phone:856-772-6331
Mailing Address - Fax:
Practice Address - Street 1:2250 ECHELON MALL
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1943
Practice Address - Country:US
Practice Address - Phone:856-772-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00460300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U38900Medicare UPIN
411493NE6Medicare ID - Type Unspecified