Healthcare Provider Details

I. General information

NPI: 1477083848
Provider Name (Legal Business Name): JAN MAGNO DE GUZMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 AUBURN PARK DR
FORT WAYNE IN
46825-2387
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 260-234-5400
  • Fax: 260-234-5110
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number01083919A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: