Healthcare Provider Details

I. General information

NPI: 1427467927
Provider Name (Legal Business Name): OMAR GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 CLAFLIN AVE APT # WA
BRONX NY
10468-2205
US

IV. Provider business mailing address

2825 CLAFLIN AVE APT WA
BRONX NY
10468-2205
US

V. Phone/Fax

Practice location:
  • Phone: 347-406-2547
  • Fax:
Mailing address:
  • Phone: 347-406-2547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number830255141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: