Provider Demographics
NPI:1225049257
Name:GALLO, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GALLO
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 1:721 RIVER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437
Mailing Address - Country:US
Mailing Address - Phone:707-961-4631
Mailing Address - Fax:707-964-1192
Practice Address - Street 1:721 RIVER DR
Practice Address - Street 2:SUITE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-4631
Practice Address - Fax:707-964-1192
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C360100OtherMEDI-CAL
CA00C360100Medicare ID - Type Unspecified
CAA36137Medicare UPIN