Provider Demographics
NPI:1629157649
Name:GRIJALVA, GALO A (MD)
Entity Type:Individual
Prefix:DR
First Name:GALO
Middle Name:A
Last Name:GRIJALVA
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 1:207 FOOTE AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-7077
Mailing Address - Country:US
Mailing Address - Phone:716-485-7870
Mailing Address - Fax:716-485-7878
Practice Address - Street 1:207 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7077
Practice Address - Country:US
Practice Address - Phone:716-485-7870
Practice Address - Fax:716-485-7878
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-082089208600000X
KY39428208600000X
NY250606208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2754087Medicaid
KY64106693Medicaid
OHH12556Medicare UPIN
OH4206101Medicare PIN