Provider Demographics
NPI:1295842342
Name:GUZMAN, GENEROSO (MD)
Entity Type:Individual
Prefix:
First Name:GENEROSO
Middle Name:
Last Name: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 1:701 E LINCOLN ST
Mailing Address - Street 2:P O BOX 489
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1738
Mailing Address - Country:US
Mailing Address - Phone:573-359-3550
Mailing Address - Fax:573-359-3557
Practice Address - Street 1:701 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1738
Practice Address - Country:US
Practice Address - Phone:573-359-3550
Practice Address - Fax:573-359-3557
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4B70207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201041613Medicaid
MOC38132Medicare UPIN
MO000004517Medicare ID - Type Unspecified