Basic Information
| Provider Information | |||||||||
| NPI: | 1932124989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JUANTEGUY | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015524 | ||||||||
| FaxNumber: | 4106018946 | ||||||||
| Practice Location | |||||||||
| Address1: | 1838 GREENE TREE RD | ||||||||
| Address2: | SUITE 285 | ||||||||
| City: | PIKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212086391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109024450 | ||||||||
| FaxNumber: | 4109024411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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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 | 208600000X | D06095 | MD | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | D06095 | MD | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | D06095 | MD | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | CB9278 | 01 | MD | R/R MEDICARE GROUP # | OTHER | P00341576 | 01 | MD | R/R MEDICARE PROVIDER # | OTHER |