Provider Demographics
NPI:1093925315
Name:GALLENERO, SERGIO M (MD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:M
Last Name:GALLENERO
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:PO BOX 8534
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33075-8534
Mailing Address - Country:US
Mailing Address - Phone:954-753-7477
Mailing Address - Fax:954-642-0258
Practice Address - Street 1:983 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-7048
Practice Address - Country:US
Practice Address - Phone:954-753-7477
Practice Address - Fax:954-642-0258
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 43373208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049514000Medicaid
FL049514000Medicaid
FL94261Medicare ID - Type Unspecified