Provider Demographics
NPI:1710972880
Name:GUILLORY, DEREK W (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:W
Last Name:GUILLORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 AVENUE A
Mailing Address - Street 2:SUITE 1118
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1264
Mailing Address - Country:US
Mailing Address - Phone:210-468-3042
Mailing Address - Fax:
Practice Address - Street 1:202 FM 1346
Practice Address - Street 2:SUITE 2
Practice Address - City:LA VERNIA
Practice Address - State:TX
Practice Address - Zip Code:78121
Practice Address - Country:US
Practice Address - Phone:830-779-3200
Practice Address - Fax:830-779-3211
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5751207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167798102Medicaid
TX167798105Medicaid
TX8M8130OtherBCBS
TX167798105Medicaid
TXP00177387Medicare PIN
TX8M8130OtherBCBS