Healthcare Provider Details

I. General information

NPI: 1902893290
Provider Name (Legal Business Name): JUAN C GUARDERAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2005
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 Code207KA0200X
TaxonomyAllergy Physician
License Number80320
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number80320
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberME62732
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: