Provider Demographics
NPI:1821119561
Name:GALLARDO, CARY WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:CARY
Middle Name:WILLIAM
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2458 SILVER LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-3236
Mailing Address - Country:US
Mailing Address - Phone:415-652-3698
Mailing Address - Fax:
Practice Address - Street 1:111 N SEPULVEDA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6849
Practice Address - Country:US
Practice Address - Phone:310-379-2134
Practice Address - Fax:310-379-4856
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93432207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU370ZMedicare PIN