Basic Information
| Provider Information | |||||||||
| NPI: | 1326234816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANTILLA | ||||||||
| FirstName: | GUILLERMO | ||||||||
| MiddleName: | ALBERTO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6555 COYLE AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956080302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165363540 | ||||||||
| FaxNumber: | 9165363541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 42647 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | C159709 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1512334 | 05 | TN | MEDICAID | 7100423880 | 05 | KY | MEDICAID | 4352401 | 01 | TN | BCBS | OTHER |