Healthcare Provider Details

I. General information

NPI: 1649764515
Provider Name (Legal Business Name): HERODES GUZMAN MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF HUMAN GENETICS
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD RM 55
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 267-426-7868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT215273
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMT215273
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMT215273
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: