Basic Information
| Provider Information | |||||||||
| NPI: | 1437113305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALERO | ||||||||
| FirstName: | GUILLERMO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1783 S KINGS AVE | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335116220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139333060 | ||||||||
| FaxNumber: | 8136624818 | ||||||||
| Practice Location | |||||||||
| Address1: | 1783 S KINGS AVE | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335116220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139333060 | ||||||||
| FaxNumber: | 8136624818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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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 | 208D00000X | ME 86710 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 260688700 | 05 | FL | MEDICAID |