Provider Demographics
NPI:1366459471
Name:PETER L GALLARELLO DPM
Entity type:Organization
Organization Name:PETER L GALLARELLO DPM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALLARELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-791-3668
Mailing Address - Street 1:1703 CIVIC CENTER DR STE 3
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7273
Mailing Address - Country:US
Mailing Address - Phone:702-791-3668
Mailing Address - Fax:
Practice Address - Street 1:1703 CIVIC CENTER DR STE 3
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7273
Practice Address - Country:US
Practice Address - Phone:702-791-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9901213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002102009Medicaid
NV002102009Medicaid
NV5494440001Medicare NSC
NVU17784Medicare UPIN