Provider Demographics
NPI:1912905290
Name:GALLO, JENNIFER L (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:GALLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:KIZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:P.O. BOX 101427
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:32910
Mailing Address - Country:US
Mailing Address - Phone:239-542-2020
Mailing Address - Fax:239-541-1492
Practice Address - Street 1:900 PINE ISLAND ROAD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991
Practice Address - Country:US
Practice Address - Phone:239-542-2020
Practice Address - Fax:239-541-1492
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620840100Medicaid
FL620840100Medicaid
FL20986ZMedicare UPIN