Healthcare Provider Details

I. General information

NPI: 1639271034
Provider Name (Legal Business Name): LUCIO N MARGALLO II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 E 5TH AVE
MITCHELL SD
57301-2917
US

IV. Provider business mailing address

1115 E 5TH AVE
MITCHELL SD
57301-2917
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-5553
  • Fax: 605-996-1213
Mailing address:
  • Phone: 605-996-5553
  • Fax: 605-996-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2266
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6000720
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier460273800
Identifier TypeOTHER
Identifier State
Identifier IssuerTAX ID
# 3
Identifier4602738000000E
Identifier TypeOTHER
Identifier State
Identifier IssuerCOMMERCIAL NUMBER ON COMP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: