Provider Demographics
NPI:1801874672
Name:GALLARDO-NAVARRA, VICTORIA (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:GALLARDO-NAVARRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2898 COLONIAL TRL
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1618
Mailing Address - Country:US
Mailing Address - Phone:248-762-6322
Mailing Address - Fax:248-334-2868
Practice Address - Street 1:2898 COLONIAL TRL
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-1618
Practice Address - Country:US
Practice Address - Phone:248-762-6322
Practice Address - Fax:248-334-2868
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI33538208600000X
OH3509365208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH107439510Medicaid
MI10-1074395Medicaid
OHB47433Medicare UPIN
OH107439510Medicaid
OH107439510Medicaid