Provider Demographics
NPI:1134342439
Name:GALLARDO, GUILLERMO G (MD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:G
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 HALPERIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2631
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:2015 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4611
Practice Address - Country:US
Practice Address - Phone:718-583-7736
Practice Address - Fax:718-537-6180
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050644207W00000X
NY197574207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF63632Medicare UPIN