Healthcare Provider Details

I. General information

NPI: 1235865627
Provider Name (Legal Business Name): VALDOSTA ALLERGY, ASTHMA, & IMMUNOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3334 GREYSTONE WAY
VALDOSTA GA
31605-1096
US

IV. Provider business mailing address

PO BOX 3068
VALDOSTA GA
31604-3068
US

V. Phone/Fax

Practice location:
  • Phone: 229-247-1667
  • Fax: 229-245-7661
Mailing address:
  • Phone: 229-247-1667
  • Fax: 229-245-7661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN C GUARDERAS
Title or Position: OWNER
Credential: MD
Phone: 229-247-1667