Provider Demographics
NPI:1811967748
Name:GUEVARA, PABLO IVAN (MD)
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:IVAN
Last Name:GUEVARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 A SAN PABLO TOWN CENTER
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806
Mailing Address - Country:US
Mailing Address - Phone:510-237-2802
Mailing Address - Fax:
Practice Address - Street 1:100 A SAN PABLO TOWN CENTER
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-237-2802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209337207R00000X
CAC162697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110004487AMedicaid
MA110004487AMedicaid
MAA32827Medicare ID - Type Unspecified