Healthcare Provider Details

I. General information

NPI: 1992741326
Provider Name (Legal Business Name): CARLOS GALLEGOS RIVERA M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 MEMORIAL PKWY
LONG BRANCH NJ
07740-6701
US

IV. Provider business mailing address

26 DAKARLA DR
MIDDLETOWN NJ
07748-3171
US

V. Phone/Fax

Practice location:
  • Phone: 732-728-7010
  • Fax: 732-728-0704
Mailing address:
  • Phone: 732-957-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number25MA06184200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: