Provider Demographics
NPI:1396793204
Name:GALLEGOS, AMY RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:RENEE
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 S LOGAN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3700
Mailing Address - Country:US
Mailing Address - Phone:303-789-7486
Mailing Address - Fax:303-789-7494
Practice Address - Street 1:3531 S LOGAN ST STE A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-3700
Practice Address - Country:US
Practice Address - Phone:303-789-7486
Practice Address - Fax:303-789-7494
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2384152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60272538Medicaid
COCOA109554OtherMEDICARE PTAN
CO911208OtherEYEMED
CO911208OtherEYEMED