Provider Demographics
NPI:1881828010
Name:GUZMAN TREVINO, GUILLERMO M (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:M
Last Name:GUZMAN TREVINO
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:4424 E FLAMINGO
Practice Address - Street 2:SUITE 200
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9300
Practice Address - Country:US
Practice Address - Phone:208-288-4888
Practice Address - Fax:208-288-4890
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29170207V00000X
IDM-12168207V00000X
ORMD-29170207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500609069Medicaid
ID808416200OtherIDAHO MEDICAID