Provider Demographics
NPI:1952345324
Name:GUILLEN, MARIO F (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:F
Last Name:GUILLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10115 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3105
Mailing Address - Country:US
Mailing Address - Phone:561-793-1117
Mailing Address - Fax:561-793-1762
Practice Address - Street 1:10115 FOREST HILL BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3105
Practice Address - Country:US
Practice Address - Phone:561-793-1117
Practice Address - Fax:561-793-1762
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME84093207R00000X
FLME 84093208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266849100Medicaid
FL266849100Medicaid
FL78736XMedicare PIN
FL78736Medicare PIN
FLG17368Medicare UPIN