Provider Demographics
NPI:1689966145
Name:GALLEGOS, MAXX (MD)
Entity type:Individual
Prefix:
First Name:MAXX
Middle Name:
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAX
Other - Middle Name:
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:5495 ARAPAHOE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1225
Practice Address - Country:US
Practice Address - Phone:512-446-9486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU6956208800000X
CAC191208208800000X
CODR0072419208800000X
NMMD2017-0027208800000X
NMNMMD2017-0027208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty