Provider Demographics
NPI:1568478493
Name:ZEGARRA, GUILLERMO G (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:G
Last Name:ZEGARRA
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 1:2182 HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6757
Mailing Address - Country:US
Mailing Address - Phone:928-758-6420
Mailing Address - Fax:928-758-6509
Practice Address - Street 1:2182 HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6044
Practice Address - Country:US
Practice Address - Phone:928-758-6420
Practice Address - Fax:928-758-6509
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32150207R00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS932401Medicaid
AS932401Medicaid