Provider Demographics
NPI:1467947366
Name:MAZA MALAVE, GUILLERMO (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:MAZA MALAVE
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:ONE BROOKDALE PLAZA, BROOKLYN
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:11212
Mailing Address - Country:US
Mailing Address - Phone:718-240-6738
Mailing Address - Fax:
Practice Address - Street 1:720 N BOND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4952
Practice Address - Country:US
Practice Address - Phone:217-545-4777
Practice Address - Fax:217-545-0836
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125074511207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program