Provider Demographics
NPI:1790734820
Name:GAGLIARDI, RAYMOND JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JOSEPH
Last Name:GAGLIARDI
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2902
Mailing Address - Fax:319-356-8378
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2902
Practice Address - Fax:319-356-8378
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38968208600000X
IAMD-46060208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64082191Medicaid
OH2176210Medicaid
KY64082191Medicaid
OH4269151Medicare PIN