Provider Demographics
NPI:1861018178
Name:GALLIK, JOHN C (IDMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:GALLIK
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6858 ASHBURY DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-7821
Mailing Address - Country:US
Mailing Address - Phone:540-220-0056
Mailing Address - Fax:
Practice Address - Street 1:3176 CORPORAL JOHNSON ROAD
Practice Address - Street 2:
Practice Address - City:JBSA FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:33809
Practice Address - Country:US
Practice Address - Phone:540-220-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians