Healthcare Provider Details

I. General information

NPI: 1811092414
Provider Name (Legal Business Name): MANUEL GUILLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 34 D COLVIN RUN ROAD
GREAT FALLS VA
22066
US

IV. Provider business mailing address

101 34 D COLVIN RUN ROAD
GREAT FALLS VA
22066
US

V. Phone/Fax

Practice location:
  • Phone: 703-757-7950
  • Fax:
Mailing address:
  • Phone: 703-757-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0101032457
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: