Healthcare Provider Details

I. General information

NPI: 1659586428
Provider Name (Legal Business Name): GARY S DEGUZMAN, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 CHAPLINE ST SUITE306
WHEELING WV
26003-3859
US

IV. Provider business mailing address

2115 CHAPLINE ST SUITE306
WHEELING WV
26003-3859
US

V. Phone/Fax

Practice location:
  • Phone: 304-234-1817
  • Fax: 304-234-8448
Mailing address:
  • Phone: 304-234-1817
  • Fax: 304-234-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number19734
License Number StateWV

VIII. Authorized Official

Name: DR. GARY S DEGUZMAN
Title or Position: OWNER
Credential: M.D.
Phone: 304-234-1817