Provider Demographics
NPI:1013206614
Name:DEGUZMAN, JACKI MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JACKI
Middle Name:MARIE
Last Name:DEGUZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:702-854-3259
Practice Address - Street 1:10105 BANBURRY CROSS DR
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6646
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:702-854-3259
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15384207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01612764OtherRAILROAD MEDICARE
NVV108806OtherSMA CONVENIENT CARE MEDICARE
NVV108640Medicare PIN