Provider Demographics
NPI:1821213323
Name:MANUEL GALLEGO MD PA
Entity type:Organization
Organization Name:MANUEL GALLEGO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:GALLEGO
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:941-764-6300
Mailing Address - Street 1:PO BOX 510298
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-0298
Mailing Address - Country:US
Mailing Address - Phone:041-764-6300
Mailing Address - Fax:941-764-7297
Practice Address - Street 1:3466 DEPEW AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-7015
Practice Address - Country:US
Practice Address - Phone:941-764-6300
Practice Address - Fax:941-764-7297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0004146103TC1900X
FLME00761192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3182Medicare ID - Type UnspecifiedGROUP NUMBER