Provider Demographics
NPI:1871897058
Name:RAPHAEL F. GUANZON, M.D., PLLC
Entity type:Organization
Organization Name:RAPHAEL F. GUANZON, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:FAJARDO
Authorized Official - Last Name:GUANZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-399-0513
Mailing Address - Street 1:704 LONDON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2413
Mailing Address - Country:US
Mailing Address - Phone:757-399-0513
Mailing Address - Fax:757-465-0785
Practice Address - Street 1:704 LONDON ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2413
Practice Address - Country:US
Practice Address - Phone:757-399-0513
Practice Address - Fax:757-465-0785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101026720208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA003121OtherANTHEM
VAB06418Medicare UPIN