Provider Demographics
NPI:1649262650
Name:GAGLIARDI, MARTIN PHILIP (MD,FACS)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:PHILIP
Last Name:GAGLIARDI
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MARTY P GAGLIARDI, MD
Mailing Address - Street 2:827 EDEN DRIVE
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-5960
Mailing Address - Country:US
Mailing Address - Phone:850-257-3708
Mailing Address - Fax:
Practice Address - Street 1:1393 VETERANS MEMORIAL HWY STE 110N
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3000
Practice Address - Country:US
Practice Address - Phone:631-851-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077321207X00000X
WAMD00043362207X00000X
NY248554207XX0801X
FL621177778174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1031985Medicaid
VA1649262650Medicaid
VAVVM446AMedicare PIN
VAP01736018Medicare PIN