Basic Information
| Provider Information | |||||||||
| NPI: | 1558335596 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLO | ||||||||
| FirstName: | ROEL | ||||||||
| MiddleName: | ANGEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20490 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852770490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
| FaxNumber: | 4809850468 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
| FaxNumber: | 4809850468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 01/24/2008 | ||||||||
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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 | 207ZP0102X | 21021 | AZ | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | AX5901 | 01 | AZ | HEALTHNET PROV NUMBER | OTHER | CB2931 | 01 | AZ | RR MC GROUP PROV NUMBER | OTHER | 497025 | 05 | AZ | MEDICAID | AZ0876870 | 01 | AZ | BCBS PROVIDER NUMBER | OTHER |