Provider Demographics
NPI:1952430811
Name:GUASTAVINO, ELLA MARIE (MD)
Entity Type:Individual
Prefix:
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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 PINE ST UNIT 216-217
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-4418
Mailing Address - Country:US
Mailing Address - Phone:941-474-5093
Mailing Address - Fax:941-474-9049
Practice Address - Street 1:900 EAST PINE STREET
Practice Address - Street 2:UNITS 216-217
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-4418
Practice Address - Country:US
Practice Address - Phone:941-474-5093
Practice Address - Fax:941-474-9049
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222304163W00000X
NY185936208000000X
FLME00599642080P0006X, 261QM0855X
FL0059964208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054127300Medicaid