Provider Demographics
NPI:1275520793
Name:GALLEGO, MANOLO (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOLO
Middle Name:
Last Name:GALLEGO
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 1:880 CANTON RD NE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7276
Mailing Address - Country:US
Mailing Address - Phone:770-528-9788
Mailing Address - Fax:770-420-2229
Practice Address - Street 1:880 CANTON RD NE
Practice Address - Street 2:SUITE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7276
Practice Address - Country:US
Practice Address - Phone:770-528-9788
Practice Address - Fax:770-420-2229
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036745174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00691182FMedicaid
GA000691182ABMedicaid
GA00691182EMedicaid
GAG11649Medicare UPIN
GA11SCFCSMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER