Provider Demographics
NPI:1619244258
Name:GALLINA, PAUL M (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:M
Last Name:GALLINA
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1619 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6930
Mailing Address - Country:US
Mailing Address - Phone:201-947-9797
Mailing Address - Fax:201-947-9790
Practice Address - Street 1:1619 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6930
Practice Address - Country:US
Practice Address - Phone:201-947-9797
Practice Address - Fax:201-947-9790
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD2212156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician