1902893290 NPI number — JUAN C GUARDERAS MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902893290 NPI number — JUAN C GUARDERAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUARDERAS
Provider First Name:
JUAN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1902893290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31604-3068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-247-1667
Provider Business Mailing Address Fax Number:
229-245-7661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3334 GREYSTONE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31605-1096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-247-1667
Provider Business Practice Location Address Fax Number:
229-245-7661
Provider Enumeration Date:
10/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  80320 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: 80320 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207K00000X , with the licence number: ME62732 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 261325500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000892966A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18056 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 030002009 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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