Provider Demographics
NPI:1235103532
Name:DEGUZMAN, SAMUEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:G
Last Name:DEGUZMAN
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 1:450 KENNEDY DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-937-5900
Mailing Address - Fax:815-937-1748
Practice Address - Street 1:450 KENNEDY DRIVE
Practice Address - Street 2:SUITE 5
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-937-5900
Practice Address - Fax:815-937-1748
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047840Medicaid
C38607Medicare UPIN
IL653150Medicare ID - Type Unspecified