Provider Demographics
NPI:1336159607
Name:GALLARDO, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GALLARDO
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5252
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:104 ASBURY CIR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1302
Practice Address - Country:US
Practice Address - Phone:601-268-5252
Practice Address - Fax:601-268-5190
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17102207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123829Medicaid
MS1559339OtherAMERICAN ADMIN GROUP
LA1768162Medicaid
MS1559339OtherAMERICAN ADMIN GROUP
MS1559339OtherAMERICAN ADMIN GROUP
MS070000093Medicare PIN