Provider Demographics
NPI:1669440061
Name:DEGUZMAN-BERUBE, ELEANOR LYNN (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:LYNN
Last Name:DEGUZMAN-BERUBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 KNELLS RIDGE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4885
Mailing Address - Country:US
Mailing Address - Phone:757-436-1234
Mailing Address - Fax:757-548-3665
Practice Address - Street 1:108 KNELLS RIDGE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4885
Practice Address - Country:US
Practice Address - Phone:757-436-1234
Practice Address - Fax:757-548-3665
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080140047OtherRAILROAD MEDICARE
VA264508OtherANTHEM BCBS
5524667OtherAETNA
VA5636167Medicaid
CIGNAOther2890231
G86722Medicare UPIN
VA5636167Medicaid