Provider Demographics
NPI:1609801489
Name:GALLO, SAMUEL A (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:GALLO
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 1:6620 PERIMETER DR
Mailing Address - Street 2:STE 100A
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-8061
Mailing Address - Country:US
Mailing Address - Phone:614-766-5438
Mailing Address - Fax:614-408-8269
Practice Address - Street 1:6620 PERIMETER DR
Practice Address - Street 2:STE 100
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8055
Practice Address - Country:US
Practice Address - Phone:614-766-5438
Practice Address - Fax:614-408-8269
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-082078207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2432657Medicaid
OH000000501524OtherANTHEM
OHP00339703OtherRR MEDICARE UP
OHG86988Medicare UPIN
OH4117393Medicare PIN