Healthcare Provider Details

I. General information

NPI: 1174703904
Provider Name (Legal Business Name): ERNEST V. DE GUZMAN, M.D., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 1ST AVE
SAN DIEGO CA
92103-5816
US

IV. Provider business mailing address

3010 1ST AVE
SAN DIEGO CA
92103-5816
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-2189
  • Fax: 619-295-2362
Mailing address:
  • Phone: 619-295-2189
  • Fax: 619-295-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA95424
License Number StateCA

VIII. Authorized Official

Name: DR. ERNEST VISPERAS DE GUZMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-295-2189