Provider Demographics
NPI:1578670394
Name:GALLARDO, RAFAEL L (MD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:L
Last Name:GALLARDO
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3610
Mailing Address - Fax:812-242-3630
Practice Address - Street 1:1711 N 6 1/2 ST
Practice Address - Street 2:STE 200
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2766
Practice Address - Country:US
Practice Address - Phone:812-242-3610
Practice Address - Fax:812-242-3630
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060896A207RH0003X
IL36068281207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200524590BMedicaid
IN200524590GMedicaid
IN200524590TMedicaid
INP00834944OtherRAILROAD MEDICARE
IN200524590KMedicaid
IN200524590LMedicaid
IN200524590YMedicaid
IN200524590ZMedicaid
000000372569OtherANTHEM
P00268119OtherRAILROAD MCARE PALAMETTO
IN200524590ZMedicaid
IN200524590LMedicaid
IN230650FMedicare PIN
000000372569OtherANTHEM
P00268119OtherRAILROAD MCARE PALAMETTO
IN200524590TMedicaid
ILK27046Medicare PIN
IN200524590KMedicaid
IN301550TMedicare PIN
B22849Medicare UPIN
ILIL3294004Medicare PIN