Healthcare Provider Details

I. General information

NPI: 1548207038
Provider Name (Legal Business Name): GUILLERMO HIDALGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 DAVIS AVE FL 5
NEPTUNE NJ
07753-4488
US

IV. Provider business mailing address

3600 ROUTE 66 FL 3
NEPTUNE NJ
07753-2605
US

V. Phone/Fax

Practice location:
  • Phone: 732-897-3400
  • Fax: 732-897-3481
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301084948
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036117155
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number2011-00127
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number25MA10679200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: