Provider Demographics
NPI:1790702777
Name:GALLIVAN, WILLIAM R JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:GALLIVAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W JUNIPERO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4305
Mailing Address - Country:US
Mailing Address - Phone:805-220-6020
Mailing Address - Fax:805-284-0085
Practice Address - Street 1:320 W JUNIPERO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4305
Practice Address - Country:US
Practice Address - Phone:805-220-6020
Practice Address - Fax:805-284-0085
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2015-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73901207X00000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F17011Medicare UPIN
CB225921Medicare PIN
WG73901BMedicare PIN
CA00G739010Medicaid
CAW745Medicare PIN