Provider Demographics
NPI:1922189141
Name:GALLAGHER, THOMAS (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:GALLAGHER
Suffix:
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 1:920 MAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4147
Mailing Address - Country:US
Mailing Address - Phone:303-545-5665
Mailing Address - Fax:
Practice Address - Street 1:1140 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8910
Practice Address - Country:US
Practice Address - Phone:303-604-1444
Practice Address - Fax:303-666-0911
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO496128Medicare ID - Type Unspecified
COH51152Medicare UPIN