Provider Demographics
NPI:1003104464
Name:GALLARDO, DIEGO ALBERTO
Entity Type:Individual
Prefix:DR
First Name:DIEGO
Middle Name:ALBERTO
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:D2 CALLE 2 ALT. DE SANS SOUCI
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957
Mailing Address - Country:US
Mailing Address - Phone:787-243-0269
Mailing Address - Fax:
Practice Address - Street 1:SUITE 201, GUAYNABO RADIOLOGY & MEDICAL PLAZA
Practice Address - Street 2:10 AVE LAS CUMBRES
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:787-233-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014159801223S0112X
PR33151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery