Provider Demographics
NPI:1427150325
Name:GALLEGO, KELLY MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MATTHEW
Last Name:GALLEGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:460 PLUMAS BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-5005
Practice Address - Country:US
Practice Address - Phone:530-749-3360
Practice Address - Fax:530-749-3491
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2015-07-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IA38653208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1592002Medicare PIN