Provider Demographics
NPI:1639484686
Name:GALLEGO-ECKSTEIN, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:GALLEGO-ECKSTEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SYMPHONY RD
Mailing Address - Street 2:APT 7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-4022
Mailing Address - Country:US
Mailing Address - Phone:954-682-9303
Mailing Address - Fax:
Practice Address - Street 1:100 E NEWTON ST
Practice Address - Street 2:ROOM G-317
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2308
Practice Address - Country:US
Practice Address - Phone:617-638-4705
Practice Address - Fax:617-638-4713
Is Sole Proprietor?:No
Enumeration Date:2010-08-15
Last Update Date:2010-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program