Basic Information
| Provider Information | |||||||||
| NPI: | 1679199731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUZMAN PEREZ | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | FONT BERNARD #4 , SAN GERONIMO | ||||||||
| Address2: | |||||||||
| City: | SANTO DOMINGO | ||||||||
| State: | DISTRITO NACIONAL | ||||||||
| PostalCode: | 10104 | ||||||||
| CountryCode: | DO | ||||||||
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| Practice Location | |||||||||
| Address1: | 82-68 164TH STREET JAMAICA | ||||||||
| Address2: | |||||||||
| City: | QUEENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188834847 | ||||||||
| FaxNumber: | 7188836197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2020 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/17/2022 | ||||||||
| NPIReactivationDate: | 03/01/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.