Basic Information
| Provider Information | |||||||||
| NPI: | 1265510291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLOUSIS | ||||||||
| FirstName: | SPIRO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6209 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112042702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182340073 | ||||||||
| FaxNumber: | 7182368456 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 78TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112093403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182381276 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 091787 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00147195 | 05 | NY | MEDICAID |