Healthcare Provider Details

I. General information

NPI: 1750367660
Provider Name (Legal Business Name): MARTHA GUZMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAKE DR E
CHANHASSEN MN
55317-9302
US

IV. Provider business mailing address

6465 WAYZATA BLVD SUITE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34391
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: