Healthcare Provider Details

I. General information

NPI: 1023749314
Provider Name (Legal Business Name): CAMILO ANDRES GUZMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2022
Last Update Date: 06/18/2022
Certification Date: 06/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1 FORD PL # 1C-09
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-6611
  • Fax:
Mailing address:
  • Phone: 313-874-6611
  • Fax: 313-874-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4351049946
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: