Provider Demographics
NPI:1811100142
Name:GIALLANZA, PETERSON FORTUNATO (MD)
Entity type:Individual
Prefix:
First Name:PETERSON
Middle Name:FORTUNATO
Last Name:GIALLANZA
Suffix:
Gender:
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10305 HAMPTONS PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7221
Practice Address - Country:US
Practice Address - Phone:704-316-5388
Practice Address - Fax:704-316-1848
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007019022084N0008X, 2084D0003X, 2084N0600X, 2084P0005X, 2084S0012X, 2084V0102X, 2084N0400X
NC2007-019022084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic Neuroimaging
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology