Provider Demographics
NPI:1578621942
Name:QUISPE, GUILLERMO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:QUISPE
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 1:3100 GA HIGHWAY 24 E
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-4568
Mailing Address - Country:US
Mailing Address - Phone:478-552-0691
Mailing Address - Fax:
Practice Address - Street 1:3100 GA HIGHWAY 24 E
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-4568
Practice Address - Country:US
Practice Address - Phone:478-552-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21574208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery