Provider Demographics
NPI:1316392707
Name:GUEVARA, JACK (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GUEVARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W. CARSON ST. BOX 461
Mailing Address - Street 2:HARBOR-UCLA MEDICAL CENTER
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90509
Mailing Address - Country:US
Mailing Address - Phone:310-222-2700
Mailing Address - Fax:
Practice Address - Street 1:160 NW 170TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33169-5576
Practice Address - Country:US
Practice Address - Phone:305-651-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17043207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology