Provider Demographics
NPI:1831132711
Name:PALACIOS, GUILLERMO A (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:A
Last Name:PALACIOS
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 1:1499 WALTON WAY, SUITE 1400
Mailing Address - Street 2:ATTN: DONNA RAIFORD
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2660
Mailing Address - Country:US
Mailing Address - Phone:706-828-8401
Mailing Address - Fax:706-722-7235
Practice Address - Street 1:3501 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5421
Practice Address - Country:US
Practice Address - Phone:954-987-2000
Practice Address - Fax:954-437-6628
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME996502085R0202X
GA0670732085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA067073OtherMEDICAL LICENSE
GA067073OtherMEDICAL LICENSE
TX8D9064Medicare PIN
TX8D9064Medicare PIN