Provider Demographics
NPI:1760410757
Name:GALLENO, HUMBERTO A (MD)
Entity Type:Individual
Prefix:DR
First Name:HUMBERTO
Middle Name:A
Last Name:GALLENO
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 1:315 N 3RD AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1905
Mailing Address - Country:US
Mailing Address - Phone:626-332-1194
Mailing Address - Fax:626-915-3162
Practice Address - Street 1:315 N 3RD AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1905
Practice Address - Country:US
Practice Address - Phone:626-332-1194
Practice Address - Fax:626-915-3162
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38401207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G384010Medicaid
CAG38401Medicare ID - Type Unspecified
CAA91990Medicare UPIN