Provider Demographics
NPI:1770151714
Name:GUERRA FUNDORA, CARLOS JAVIER
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:JAVIER
Last Name:GUERRA FUNDORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7253 SW 158TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-3306
Mailing Address - Country:US
Mailing Address - Phone:786-329-3837
Mailing Address - Fax:
Practice Address - Street 1:7253 SW 158TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-3306
Practice Address - Country:US
Practice Address - Phone:786-329-3837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20-124588106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107527700Medicaid