Healthcare Provider Details

I. General information

NPI: 1285671412
Provider Name (Legal Business Name): LEVI L GUERRERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 MAIN ST
DECKERVILLE MI
48427-9615
US

IV. Provider business mailing address

3532 MAIN ST
DECKERVILLE MI
48427-9615
US

V. Phone/Fax

Practice location:
  • Phone: 810-376-3100
  • Fax: 810-376-8311
Mailing address:
  • Phone: 810-376-3100
  • Fax: 810-376-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number43010038491
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier103365954
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 2
Identifier5067217
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerAETNA
# 3
Identifier0107600112
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBC/BS/BC NETWORK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: