Provider Demographics
NPI:1013997121
Name:GALLISTEL, LAURA JEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JEAN
Last Name:GALLISTEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 REDBIRD CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7979
Mailing Address - Country:US
Mailing Address - Phone:920-338-6820
Mailing Address - Fax:
Practice Address - Street 1:555 REDBIRD CIR STE 200
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7979
Practice Address - Country:US
Practice Address - Phone:920-338-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51423-021208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI430800029Medicare Oscar/Certification
WI073550087Medicare Oscar/Certification
WI002150234Medicare Oscar/Certification
WI07290062Medicare Oscar/Certification