Basic Information
| Provider Information | |||||||||
| NPI: | 1578670394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLARDO | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423610 | ||||||||
| FaxNumber: | 8122423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 N 6 1/2 ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423610 | ||||||||
| FaxNumber: | 8122423630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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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 | 207RH0003X | 01060896A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 36068281 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200524590B | 05 | IN | MEDICAID | 200524590G | 05 | IN | MEDICAID | 200524590T | 05 | IN | MEDICAID | P00834944 | 01 | IN | RAILROAD MEDICARE | OTHER | 200524590K | 05 | IN | MEDICAID | 200524590L | 05 | IN | MEDICAID | 200524590Y | 05 | IN | MEDICAID | 200524590Z | 05 | IN | MEDICAID | 000000372569 | 01 | ANTHEM | OTHER | P00268119 | 01 | RAILROAD MCARE PALAMETTO | OTHER |