Provider Demographics
NPI:1134987795
Name:GALLARDO, ROBERT LUIS ((RT) R)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LUIS
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:(RT) R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12012 NE 110TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-1681
Mailing Address - Country:US
Mailing Address - Phone:541-206-0789
Mailing Address - Fax:
Practice Address - Street 1:19300 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7706
Practice Address - Country:US
Practice Address - Phone:541-206-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR918782247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist