Basic Information
| Provider Information | |||||||||
| NPI: | 1548207038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIDALGO | ||||||||
| FirstName: | GUILLERMO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 ROUTE 66 FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077532605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328070877 | ||||||||
| FaxNumber: | 2017511680 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 DAVIS AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077534488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328973400 | ||||||||
| FaxNumber: | 7328973481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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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 | 208000000X | 4301084948 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0210X | 036117155 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 2080P0210X | 2011-00127 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 2080P0210X | 25MA10679200 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 5916951 | 05 | NC | MEDICAID | 161WY | 01 | NC | BCBSNC | OTHER | 036117155 | 01 | IL | MEDICAL LICENSE | OTHER |