Provider Demographics
NPI:1174654040
Name:GALLARDO, ANTONIO JOSE (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:JOSE
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STREET 22 BLOCK 51
Mailing Address - Street 2:#63 SANTA ROSA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:787-780-4346
Mailing Address - Fax:787-780-4576
Practice Address - Street 1:CALLE 22 BLOQUE 51
Practice Address - Street 2:#63 SANTA ROSA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-780-4346
Practice Address - Fax:787-780-4576
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6693261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR6693OtherSTATE LINCENSE