Provider Demographics
NPI:1780664631
Name:GUANZON, MARIE DENISE ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE DENISE
Middle Name:ALFONSO
Last Name:GUANZON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:701-530-7000
Mailing Address - Fax:701-530-8842
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:701-530-7000
Practice Address - Fax:701-530-8842
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9430208M00000X
MN53336207R00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13077Medicaid
NDP00327845OtherRR MEDICARE
ND13077Medicaid
NDN712041Medicare PIN