Provider Demographics
NPI:1841505187
Name:GUILLERMO, MELISSA (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GUILLERMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 BARD AVE RM 314
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1699
Mailing Address - Country:US
Mailing Address - Phone:925-384-7761
Mailing Address - Fax:718-818-2739
Practice Address - Street 1:355 BARD AVE RM 314
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1699
Practice Address - Country:US
Practice Address - Phone:718-818-4636
Practice Address - Fax:718-818-2739
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3192422080N0001X
NJ25MA10792300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine