Provider Demographics
NPI:1386668499
Name:SAN ROMAN, GUILLERMO A (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:A
Last Name:SAN ROMAN
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 1:1630 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5210
Mailing Address - Country:US
Mailing Address - Phone:631-242-6166
Mailing Address - Fax:631-242-8768
Practice Address - Street 1:1630 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5210
Practice Address - Country:US
Practice Address - Phone:631-242-6166
Practice Address - Fax:631-242-8768
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150903207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01453130Medicaid
NY01453130Medicaid
NYB20462Medicare UPIN