Provider Demographics
NPI:1780734699
Name:GUAJARDO, MANUEL G (MD, PA)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:G
Last Name:GUAJARDO
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LORENALY DRIVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-4446
Mailing Address - Country:US
Mailing Address - Phone:956-350-5007
Mailing Address - Fax:956-350-0945
Practice Address - Street 1:301 LORENALY DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-4446
Practice Address - Country:US
Practice Address - Phone:956-350-5007
Practice Address - Fax:956-350-0945
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5128207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084800401Medicaid
TX00R48WMedicare ID - Type Unspecified
TX084800401Medicaid