1205161239 NPI number — ANTHONY DEGUZMAN MD PSC

Table of content: (NPI 1205161239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205161239 NPI number — ANTHONY DEGUZMAN MD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY DEGUZMAN MD PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ANTHONY DEGUZMAN MD
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205161239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 BROADWAY STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAINTSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-789-4450
Provider Business Mailing Address Fax Number:
606-789-4452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINTSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41240-1348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-789-4450
Provider Business Practice Location Address Fax Number:
606-789-4452
Provider Enumeration Date:
10/08/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEGUZMAN
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
ASUNCION
Authorized Official Title or Position:
DOCTOR / OWNER
Authorized Official Telephone Number:
606-789-4450

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  31110 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64311103 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".