Provider Demographics
NPI:1073517686
Name:FERNANDO, VICTORIA DE GUZMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:DE GUZMAN
Last Name:FERNANDO
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 1:2100 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-7335
Mailing Address - Fax:575-769-7336
Practice Address - Street 1:2100 N MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:601-765-3180
Practice Address - Fax:601-765-2808
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-0102207PE0004X
MS18178207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00737798Medicaid
BF8479506OtherDEA
080003771Medicare PIN
H91947Medicare UPIN