Provider Demographics
NPI:1831451632
Name:BRENT WESLEY GALLOWAY JR MD PLLC
Entity type:Organization
Organization Name:BRENT WESLEY GALLOWAY JR MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:918-891-8231
Mailing Address - Street 1:3913 STABLEGLEN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-0129
Mailing Address - Country:US
Mailing Address - Phone:918-891-8231
Mailing Address - Fax:
Practice Address - Street 1:3913 STABLEGLEN DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-0129
Practice Address - Country:US
Practice Address - Phone:918-891-8231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK29413OtherOK MED LICENSE
TXN4420OtherMEDICAL LICENSE