Provider Demographics
NPI:1164490330
Name:GUILLOT, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:GUILLOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 986513
Mailing Address - Street 2:DEPT 100
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02298-6513
Mailing Address - Country:US
Mailing Address - Phone:910-219-8326
Mailing Address - Fax:910-939-4269
Practice Address - Street 1:152 MEMORIAL CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6322
Practice Address - Country:US
Practice Address - Phone:910-346-3976
Practice Address - Fax:910-353-0600
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020599207K00000X
NC2021-01998208D00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1905445Medicaid
NC1164490330Medicaid