Provider Demographics
NPI:1407929920
Name:ISMAEL GUERRERO MD PLLC
Entity Type:Organization
Organization Name:ISMAEL GUERRERO MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:INCLAN
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-5951
Mailing Address - Street 1:1965 WEST 24TH STREET
Mailing Address - Street 2:STE A
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-344-5951
Mailing Address - Fax:928-344-5779
Practice Address - Street 1:1965 WEST 24TH STREET
Practice Address - Street 2:STE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364
Practice Address - Country:US
Practice Address - Phone:928-344-5951
Practice Address - Fax:928-344-5779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21545207Q00000X
AZ2891363A00000X
AZ1458363A00000X
AZ2125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ139841Medicaid
AZ502098Medicaid
AZA89964Medicare UPIN
AZ502098Medicaid
AZQ18535Medicare UPIN
AZP00059Medicare UPIN
AZZ82382Medicare PIN