Provider Demographics
NPI:1174512198
Name:DE GUZMAN, EDSON (MD)
Entity Type:Individual
Prefix:DR
First Name:EDSON
Middle Name:
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13572 WATERFORD PL
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3928
Mailing Address - Country:US
Mailing Address - Phone:804-560-8828
Mailing Address - Fax:804-525-2520
Practice Address - Street 1:13572 WATERFORD PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3928
Practice Address - Country:US
Practice Address - Phone:804-560-8782
Practice Address - Fax:804-525-2525
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057505207RC0000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005862833Medicaid
BD7322629OtherDEA
VA005862833Medicaid
BD7322629OtherDEA