Provider Demographics
NPI:1407896913
Name:GALLARDO, IGNACIO L (MD)
Entity Type:Individual
Prefix:DR
First Name:IGNACIO
Middle Name:L
Last Name:GALLARDO
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 1:1134 N ROAD ST
Mailing Address - Street 2:BLDG09
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3365
Mailing Address - Country:US
Mailing Address - Phone:252-338-9451
Mailing Address - Fax:252-338-9170
Practice Address - Street 1:1134 N ROAD ST
Practice Address - Street 2:BLDG09
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3365
Practice Address - Country:US
Practice Address - Phone:252-338-9451
Practice Address - Fax:252-338-9170
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76744207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254846100Medicaid
FL44376OtherBLUE CROSS BLUE SHIELD
FL44376YMedicare PIN
FL44376WMedicare PIN
FL254846100Medicaid