1013206614 NPI number — JACKI MARIE DEGUZMAN M.D.

Table of content: JACKI MARIE DEGUZMAN M.D. (NPI 1013206614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013206614 NPI number — JACKI MARIE DEGUZMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGUZMAN
Provider First Name:
JACKI
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1013206614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15645
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89114-5645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-877-5199
Provider Business Mailing Address Fax Number:
702-854-3259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10105 BANBURRY CROSS DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89144-6646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-877-5199
Provider Business Practice Location Address Fax Number:
702-854-3259
Provider Enumeration Date:
04/04/2011

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: 207R00000X , with the licence number:  15384 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01612764 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: V108806 . This is a "SMA CONVENIENT CARE MEDICARE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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