Provider Demographics
NPI:1447344825
Name:GUZMAN, LUELLA M (MD)
Entity type:Individual
Prefix:
First Name:LUELLA
Middle Name:M
Last Name:GUZMAN
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-563-4466
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:500 MCMILLEN ST
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1233
Practice Address - Country:US
Practice Address - Phone:920-563-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG151934208000000X, 208000000X
WI74002-20208000000X
TNMD45409208000000X
NC2015-02503208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447344825Medicaid
VA1447344825Medicaid
TN1516609Medicaid
NM21385301Medicaid
G30198Medicare UPIN
VA1447344825Medicaid