Provider Demographics
NPI:1306192430
Name:PETER L GALLARELLO DPM PLLC
Entity Type:Organization
Organization Name:PETER L GALLARELLO DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALLARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-791-3668
Mailing Address - Street 1:PO BOX 26055
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89126-0055
Mailing Address - Country:US
Mailing Address - Phone:702-791-3668
Mailing Address - Fax:702-452-3668
Practice Address - Street 1:1703 CIVIC CENTER DR
Practice Address - Street 2:#3
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7212
Practice Address - Country:US
Practice Address - Phone:702-791-3668
Practice Address - Fax:702-452-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9901213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6720050001Medicare NSC
NVGQ431AMedicare PIN