Provider Demographics
NPI:1659967719
Name:GAGLIO, PIETRO DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:PIETRO
Middle Name:DAVID
Last Name:GAGLIO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15759 CANAL RD APT 202
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5019
Mailing Address - Country:US
Mailing Address - Phone:586-822-8329
Mailing Address - Fax:
Practice Address - Street 1:15759 CANAL RD APT 202
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-5019
Practice Address - Country:US
Practice Address - Phone:586-822-8329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50861208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation