Provider Demographics
NPI:1659586428
Name:GARY S DEGUZMAN, M.D., INC
Entity Type:Organization
Organization Name:GARY S DEGUZMAN, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEGUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-234-1817
Mailing Address - Street 1:2115 CHAPLINE ST
Mailing Address - Street 2:SUITE306
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3859
Mailing Address - Country:US
Mailing Address - Phone:304-234-1817
Mailing Address - Fax:304-234-8448
Practice Address - Street 1:2115 CHAPLINE ST
Practice Address - Street 2:SUITE306
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3859
Practice Address - Country:US
Practice Address - Phone:304-234-1817
Practice Address - Fax:304-234-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19734261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2160281Medicaid
WV0300027000Medicaid
WV0887261Medicare ID - Type Unspecified
WV0300027000Medicaid