Healthcare Provider Details

I. General information

NPI: 1568478493
Provider Name (Legal Business Name): GUILLERMO G ZEGARRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2182 HIGHWAY 95
BULLHEAD CITY AZ
86442-6044
US

IV. Provider business mailing address

2182 HIGHWAY 95
BULLHEAD CITY AZ
86442-6757
US

V. Phone/Fax

Practice location:
  • Phone: 928-758-6420
  • Fax: 928-758-6509
Mailing address:
  • Phone: 928-758-6420
  • Fax: 928-758-6509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number32150
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32150
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: