Healthcare Provider Details

I. General information

NPI: 1134878705
Provider Name (Legal Business Name): CHARLES DE GUZMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-3874
  • Fax:
Mailing address:
  • Phone: 617-665-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1022888
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number1022888
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: