Provider Demographics
NPI:1427231828
Name:GAANAN, CARLO GALLO (MD)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:GALLO
Last Name:GAANAN
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:PO BOX 166
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985
Mailing Address - Country:US
Mailing Address - Phone:920-426-4310
Mailing Address - Fax:920-236-4199
Practice Address - Street 1:1505 NORTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985
Practice Address - Country:US
Practice Address - Phone:920-426-4310
Practice Address - Fax:920-236-4199
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44853020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine