Provider Demographics
NPI:1144306317
Name:GALLO, RICHARD JUSTIN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:JUSTIN
Last Name:GALLO
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 1:1625 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:201-944-7676
Mailing Address - Fax:201-944-9452
Practice Address - Street 1:1625 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024
Practice Address - Country:US
Practice Address - Phone:201-944-7676
Practice Address - Fax:201-944-9452
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA54263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4992806Medicaid
E62864Medicare UPIN
682135C78Medicare ID - Type Unspecified