Provider Demographics
NPI:1659485977
Name:GALLO, MARTIN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ROBERT
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 1:21202 OWENS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2001
Mailing Address - Country:US
Mailing Address - Phone:779-334-0010
Mailing Address - Fax:779-334-0011
Practice Address - Street 1:1000 COWLES CLINC WAY STE A-100
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-5286
Practice Address - Country:US
Practice Address - Phone:706-418-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076016207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076016Medicaid
ILP00694794OtherRR MEDICARE