Healthcare Provider Details

I. General information

NPI: 1780517375
Provider Name (Legal Business Name): VIDMAR IVAN CARRILLO GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21444 CARMEAN WAY
GEORGETOWN DE
19947-4572
US

IV. Provider business mailing address

21444 CARMEAN WAY
GEORGETOWN DE
19947-4572
US

V. Phone/Fax

Practice location:
  • Phone: 302-855-1233
  • Fax: 302-654-1061
Mailing address:
  • Phone: 302-855-1233
  • Fax: 302-654-1061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0013919
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: