Provider Demographics
NPI:1407806300
Name:TREMOLS, GUILLERMO ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:ANTONIO
Last Name:TREMOLS
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 1:1712 CLUBHOUSE ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4595
Mailing Address - Country:US
Mailing Address - Phone:703-471-5770
Mailing Address - Fax:703-471-5771
Practice Address - Street 1:1712 CLUBHOUSE ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4595
Practice Address - Country:US
Practice Address - Phone:703-471-5770
Practice Address - Fax:703-471-5770
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101020286208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6720200Medicaid
VA6720200Medicaid
B94265Medicare UPIN