Provider Demographics
NPI:1396207387
Name:GALL, RYAN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ANDREW
Last Name:GALL
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 1:1233 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2321
Mailing Address - Country:US
Mailing Address - Phone:586-214-2459
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:586-214-2459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2024-07-01
Deactivation Date:2019-05-13
Deactivation Code:
Reactivation Date:2019-05-29
Provider Licenses
StateLicense IDTaxonomies
FL159051207N00000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice