Healthcare Provider Details

I. General information

NPI: 1730409178
Provider Name (Legal Business Name): GABRIEL ENRIQUE GALLARDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GABRIEL ENRIQUE GALLARDO-VELASQUEZ

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WEALTHY ST SE SUITE 180
GRAND RAPIDS MI
49506-2969
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-8501
  • Fax: 616-774-8595
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301096519
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: