Healthcare Provider Details

I. General information

NPI: 1033469382
Provider Name (Legal Business Name): MADELYN GUZMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 150TH ST
WHITESTONE NY
11357-1650
US

IV. Provider business mailing address

718 150TH ST
WHITESTONE NY
11357-1650
US

V. Phone/Fax

Practice location:
  • Phone: 917-446-9703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number520703111
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number520463111
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: