Healthcare Provider Details

I. General information

NPI: 1235015686
Provider Name (Legal Business Name): GINA C GUZMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4413 CLEEK CT
FERNANDINA BEACH FL
32034-5323
US

IV. Provider business mailing address

4413 CLEEK CT
FERNANDINA BEACH FL
32034-5323
US

V. Phone/Fax

Practice location:
  • Phone: 312-863-8256
  • Fax:
Mailing address:
  • Phone: 312-863-8256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.095050
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: