Healthcare Provider Details

I. General information

NPI: 1538111554
Provider Name (Legal Business Name): MARY C DEGUARDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 - 42 MITCHELL AVE BINGHAMTON PEDIATRICS
BINGHAMTON NY
13903
US

IV. Provider business mailing address

58 LUSK ST
JOHNSON CITY NY
13790-2541
US

V. Phone/Fax

Practice location:
  • Phone: 607-762-2468
  • Fax:
Mailing address:
  • Phone: 607-763-6293
  • Fax: 607-763-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number188996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: