Provider Demographics
NPI:1790849750
Name:GALLAP, MICHAEL RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:GALLAP
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 1:543 S SUNSET ST
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-4953
Mailing Address - Country:US
Mailing Address - Phone:808-264-0107
Mailing Address - Fax:
Practice Address - Street 1:543 S SUNSET ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-4953
Practice Address - Country:US
Practice Address - Phone:808-264-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD-617152W00000X
CAOPT-7190T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790849750OtherNPI
0734490001Medicare NSC
U31847Medicare UPIN