Provider Demographics
NPI:1558335596
Name:GALLO, ROEL ANGEL JR (MD)
Entity Type:Individual
Prefix:
First Name:ROEL
Middle Name:ANGEL
Last Name:GALLO
Suffix:JR
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 20490
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-0490
Mailing Address - Country:US
Mailing Address - Phone:480-985-1093
Mailing Address - Fax:480-985-0468
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:480-985-1093
Practice Address - Fax:480-985-0468
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21021207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAX5901OtherHEALTHNET PROV NUMBER
AZCB2931OtherRR MC GROUP PROV NUMBER
AZ497025Medicaid
AZAZ0876870OtherBCBS PROVIDER NUMBER
AZAX5901OtherHEALTHNET PROV NUMBER
AZ63636Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
G21972Medicare UPIN