1104288406 NPI number — DR. JOSEPH DAVID GALLEGO MD

Table of content: AUTUMN MCNEIL (NPI 1194580142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104288406 NPI number — DR. JOSEPH DAVID GALLEGO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLEGO
Provider First Name:
JOSEPH
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104288406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 ATLANTIC AVE STE 226
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02110-3820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-215-4647
Provider Business Mailing Address Fax Number:
769-206-4623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 ATLANTIC AVE STE 226
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02110-3820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-215-4647
Provider Business Practice Location Address Fax Number:
769-206-4623
Provider Enumeration Date:
03/25/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  56096 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 298743 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 25MA11418100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 61592 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 291328 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)