Provider Demographics
NPI:1396740932
Name:GUEVARA, DAISY J (MD)
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:J
Last Name:GUEVARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 E. SOUTH ST.
Mailing Address - Street 2:STE 303
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3650 E. SOUTH ST.
Practice Address - Street 2:STE 303
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712
Practice Address - Country:US
Practice Address - Phone:562-923-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A489660OtherMEDICAL #
CAF57085Medicare UPIN