Provider Demographics
NPI:1851385272
Name:GUILLERMO, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:GUILLERMO
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 1:250 BLOSSOM ST
Mailing Address - Street 2:STE 400
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4204
Mailing Address - Country:US
Mailing Address - Phone:281-604-1300
Mailing Address - Fax:281-724-0225
Practice Address - Street 1:250 BLOSSOM ST
Practice Address - Street 2:STE 400
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4204
Practice Address - Country:US
Practice Address - Phone:281-604-1300
Practice Address - Fax:281-724-0225
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080110914OtherRAILROAD MEDICARE
TX5994569OtherAETNA
TX045336701Medicaid
TX86Z063OtherBCBS
TX87583ZOtherHMO BLUE
TXF90879Medicare UPIN
TX86Z063Medicare PIN