Provider Demographics
NPI:1467618934
Name:GALLEGOS, MARLENE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:
Last Name:GALLEGOS
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 1:1110 64TH ST
Mailing Address - Street 2:UNIT 10
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-4586
Mailing Address - Country:US
Mailing Address - Phone:708-352-1613
Mailing Address - Fax:
Practice Address - Street 1:1750 W HARRISON ST
Practice Address - Street 2:ROOM 570 JELKE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3825
Practice Address - Country:US
Practice Address - Phone:312-942-5260
Practice Address - Fax:312-942-4228
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125052842207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology