Healthcare Provider Details

I. General information

NPI: 1164603635
Provider Name (Legal Business Name): GRACE DE GUZMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BALDWIN PARK BLVD
BALDWIN PARK CA
91706-5806
US

IV. Provider business mailing address

1011 BALDWIN PARK BLVD
BALDWIN PARK CA
91706-5806
US

V. Phone/Fax

Practice location:
  • Phone: 626-851-1011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA103279
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: