Provider Demographics
NPI:1538111554
Name:DEGUARDI, MARY C (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:DEGUARDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 LUSK ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2541
Mailing Address - Country:US
Mailing Address - Phone:607-763-6293
Mailing Address - Fax:607-763-6717
Practice Address - Street 1:10 - 42 MITCHELL AVE
Practice Address - Street 2:BINGHAMTON PEDIATRICS
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903
Practice Address - Country:US
Practice Address - Phone:607-762-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02045783Medicaid
F09743Medicare UPIN
NY02045783Medicaid