Provider Demographics
NPI:1568819845
Name:GALLEGOS, JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:GALLEGOS
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 1:146 E GENEVA SQ
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-9694
Mailing Address - Country:US
Mailing Address - Phone:262-249-5000
Mailing Address - Fax:
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9694
Practice Address - Country:US
Practice Address - Phone:262-249-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068159207Q00000X
WI71582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100091841Medicaid