Provider Demographics
NPI:1770624371
Name:GALLAGHER, GARY LYLE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYLE
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 1:2249 NW LAKESIDE PL
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1354
Mailing Address - Country:US
Mailing Address - Phone:541-728-3184
Mailing Address - Fax:
Practice Address - Street 1:777 SW MILL VIEW WAY STE 250
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1140
Practice Address - Country:US
Practice Address - Phone:541-728-3184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21961208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134297Medicaid
ORG03006Medicare UPIN
OR112946Medicare ID - Type Unspecified