Provider Demographics
NPI:1952430811
Name:GUASTAVINO, ELLA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:ELLA
Middle Name:MARIE
Last Name:GUASTAVINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7227 TEABERRY ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224-8051
Mailing Address - Country:US
Mailing Address - Phone:941-416-2864
Mailing Address - Fax:650-265-4616
Practice Address - Street 1:3217 S ACCESS RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-8644
Practice Address - Country:US
Practice Address - Phone:941-416-2864
Practice Address - Fax:650-265-4616
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185936208000000X
FLME0059964261QM0855X, 2080P0006X
NY222304163W00000X
FL0059964208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054127300Medicaid