Provider Demographics
NPI:1619568375
Name:GUZMAN, EDWIN (CGC)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:GUZMAN
Suffix:
Gender:M
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3959 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1559
Mailing Address - Country:US
Mailing Address - Phone:212-305-0293
Mailing Address - Fax:212-305-9058
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-305-0293
Practice Address - Fax:212-305-9058
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY170300000XMedicaid