Healthcare Provider Details

I. General information

NPI: 1376716274
Provider Name (Legal Business Name): JAN DAVID GALLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST DEPT. CARDIAC SURGERY, SUITE 5200
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

350 ENGLE ST DEPT. CARDIAC SURGERY, SUITE 5200
ENGLEWOOD NJ
07631-1808
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3636
  • Fax: 201-541-2188
Mailing address:
  • Phone: 201-894-3636
  • Fax: 201-541-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07969200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMA07969200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: