Provider Demographics
NPI:1518659457
Name:GALLICCHIO, ANGELO
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:GALLICCHIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-4677
Mailing Address - Country:US
Mailing Address - Phone:732-549-1373
Mailing Address - Fax:732-906-3634
Practice Address - Street 1:883 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-4677
Practice Address - Country:US
Practice Address - Phone:732-549-1373
Practice Address - Fax:732-906-3634
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ31TD00164200156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician