Provider Demographics
NPI:1174819064
Name:DE GUZMAN, GLENDELL SANTIAGO (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENDELL
Middle Name:SANTIAGO
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GLENDELL
Other - Middle Name:
Other - Last Name:DE GUZMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:
Practice Address - Street 1:6355 S BUFFALO DR FL 3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2133
Practice Address - Country:US
Practice Address - Phone:702-255-3547
Practice Address - Fax:702-921-2419
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263048207V00000X
NV18236207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV813419791OtherEMPLOYER TIN