Provider Demographics
NPI:1598084386
Name:GUADIANA, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GUADIANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-0009
Mailing Address - Country:US
Mailing Address - Phone:229-247-9911
Mailing Address - Fax:229-247-8844
Practice Address - Street 1:3374 GREYSTONE WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1096
Practice Address - Country:US
Practice Address - Phone:229-247-9911
Practice Address - Fax:229-247-8844
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078515207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1598084386OtherMEDI-CAL
CACB214961Medicare PIN