Provider Demographics
NPI:1235267782
Name:GALLITO, AMIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMIDA
Middle Name:
Last Name:GALLITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 23RD AVE E
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3739
Mailing Address - Country:US
Mailing Address - Phone:843-687-7811
Mailing Address - Fax:
Practice Address - Street 1:3520 TOWER AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-392-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050345A207Q00000X
SC21184207Q00000X
VA0101238093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine