Provider Demographics
NPI:1649469750
Name:KATHLEEN GALLAHER, M.D.
Entity type:Organization
Organization Name:KATHLEEN GALLAHER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:EMILIE
Authorized Official - Last Name:GALLAHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-974-1362
Mailing Address - Street 1:17871 SANTIAGO BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92861-4118
Mailing Address - Country:US
Mailing Address - Phone:714-974-1362
Mailing Address - Fax:714-974-3145
Practice Address - Street 1:17871 SANTIAGO BLVD STE 206
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92861-4118
Practice Address - Country:US
Practice Address - Phone:714-974-1362
Practice Address - Fax:714-974-3145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00004108OtherRAILROAD MEDICARE
CAW15972Medicare PIN