Provider Demographics
NPI:1184732992
Name:GUANZON, RAPHAEL FAJARDO (MD)
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:FAJARDO
Last Name:GUANZON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAFAEL
Other - Middle Name:FAJARDO
Other - Last Name:GUANZON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:704 LONDON ST # A
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2413
Mailing Address - Country:US
Mailing Address - Phone:757-399-0513
Mailing Address - Fax:
Practice Address - Street 1:704 LONDON ST # A
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2413
Practice Address - Country:US
Practice Address - Phone:757-399-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101026720208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005671213Medicaid
VA003121OtherANTHEM
VA003121OtherANTHEM