Provider Demographics
NPI:1659567352
Name:GILLEGO, ALYSSA (MD)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GILLEGO
Suffix:
Gender:F
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:PO BOX 415126
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5126
Mailing Address - Country:US
Mailing Address - Phone:203-863-4250
Mailing Address - Fax:203-863-4249
Practice Address - Street 1:77 LAFAYETTE PL STE 302
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5426
Practice Address - Country:US
Practice Address - Phone:203-863-4250
Practice Address - Fax:203-863-4249
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252073208600000X
CT056739208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY390200000XMedicaid
25207301OtherHEALTHFIRST
GA2073OtherATLANTIS
090923000071OtherFIDELIS
P4055272OtherOXFORD