Provider Demographics
NPI:1790509644
Name:GUZMAN, SIMON VINCENZO (LDO)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:VINCENZO
Last Name:GUZMAN
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 JESSICA WAY
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1393
Mailing Address - Country:US
Mailing Address - Phone:626-226-6992
Mailing Address - Fax:
Practice Address - Street 1:450 JESSICA WAY
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-1393
Practice Address - Country:US
Practice Address - Phone:626-226-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO003009156FC0800X, 156FX1800X
156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic