Provider Demographics
NPI:1659892016
Name:GALLARDO AVILA, PATRICIO PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIO
Middle Name:PAUL
Last Name:GALLARDO AVILA
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 1:3332 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-8732
Mailing Address - Country:US
Mailing Address - Phone:212-694-2000
Mailing Address - Fax:212-694-2936
Practice Address - Street 1:3332 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-8732
Practice Address - Country:US
Practice Address - Phone:212-694-2000
Practice Address - Fax:212-694-2936
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
09677386OtherECFMG/USMLE NUMBER