=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174634802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEGUNDO LUIS LIZARDO-GUZMAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 JAMES ST STE B
-----------------------------------------------------
City | WESLACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78596-6654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-968-1621
-----------------------------------------------------
Fax | 956-447-8626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 JAMES ST STE B
-----------------------------------------------------
City | WESLACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78596-6654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-968-1621
-----------------------------------------------------
Fax | 956-447-8626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | M4302
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------