Provider Demographics
NPI:1881872000
Name:VAN GALLERA, ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:VAN GALLERA
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 1:1480 BAXTER ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6393
Mailing Address - Country:US
Mailing Address - Phone:706-543-0228
Mailing Address - Fax:
Practice Address - Street 1:1480 BAXTER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6393
Practice Address - Country:US
Practice Address - Phone:706-543-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB69321Medicare UPIN