Healthcare Provider Details

I. General information

NPI: 1528057874
Provider Name (Legal Business Name): MAURICE A GUZMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 W 63RD ST
CHICAGO IL
60629-5010
US

IV. Provider business mailing address

4200 W 63RD ST
CHICAGO IL
60629-5010
US

V. Phone/Fax

Practice location:
  • Phone: 773-581-5660
  • Fax: 773-581-5661
Mailing address:
  • Phone: 773-581-5660
  • Fax: 773-581-5661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036098402
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: