Provider Demographics
NPI:1649659327
Name:GALLEGOS, IVAN (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:GALLEGOS
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 1:320 CARLETON AVE
Mailing Address - Street 2:SUITE 7000
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4506
Mailing Address - Country:US
Mailing Address - Phone:631-517-9261
Mailing Address - Fax:631-517-9276
Practice Address - Street 1:320 CARLETON AVE
Practice Address - Street 2:SUITE 7000
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4506
Practice Address - Country:US
Practice Address - Phone:631-517-9261
Practice Address - Fax:631-517-9276
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205128207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology