Provider Demographics
NPI:1700085578
Name:GALLUB, JENNIFER L (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:GALLUB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:GALLUB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:418 S KING ST
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-3704
Mailing Address - Country:US
Mailing Address - Phone:910-276-7570
Mailing Address - Fax:910-276-1327
Practice Address - Street 1:418 S KING ST
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-3704
Practice Address - Country:US
Practice Address - Phone:910-276-7570
Practice Address - Fax:910-276-1327
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910676Medicaid