Provider Demographics
NPI:1699201350
Name:GALLARDO RIOS, MARIA SUSANA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:SUSANA
Last Name:GALLARDO RIOS
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 1:3990 JOHN R
Mailing Address - Street 2:MEDICAL CENTER
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-745-6035
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-12-13
Deactivation Date:2017-12-06
Deactivation Code:
Reactivation Date:2017-12-13
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program