Healthcare Provider Details

I. General information

NPI: 1447344825
Provider Name (Legal Business Name): LUELLA M GUZMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MCMILLEN ST
FORT ATKINSON WI
53538-1233
US

IV. Provider business mailing address

PO BOX 249
FORT ATKINSON WI
53538-0249
US

V. Phone/Fax

Practice location:
  • Phone: 920-563-5571
  • Fax:
Mailing address:
  • Phone: 920-563-4466
  • Fax: 920-568-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG151934
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74002-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: