Provider Demographics
NPI:1053508184
Name:IVAN GUERRERO MD PA
Entity Type:Organization
Organization Name:IVAN GUERRERO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-646-1987
Mailing Address - Street 1:PO BOX 551272
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1272
Mailing Address - Country:US
Mailing Address - Phone:904-646-3017
Mailing Address - Fax:904-646-1501
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:SUITE 502
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-646-3017
Practice Address - Fax:904-646-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82361174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000802800Medicaid
FLAH113Medicare PIN