Provider Demographics
NPI:1619084258
Name:MICHAEL B. GUILLORY, MD., P.A.
Entity Type:Organization
Organization Name:MICHAEL B. GUILLORY, MD., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:GUILLORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-757-4662
Mailing Address - Street 1:3209 N 4TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5145
Mailing Address - Country:US
Mailing Address - Phone:903-757-4662
Mailing Address - Fax:
Practice Address - Street 1:3209 N 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5145
Practice Address - Country:US
Practice Address - Phone:903-757-4662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2271207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089523702Medicaid
TX2223181OtherBLUE LINK
TX826081717OtherRAIL ROAD MEDICARE
TX826081717OtherRAIL ROAD MEDICARE
TX00Y998Medicare Oscar/Certification