Basic Information
| Provider Information | |||||||||
| NPI: | 1639175458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRA | ||||||||
| FirstName: | JIM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1204 KITTERY DR | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751158132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128108611 | ||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1204 KITTERY DR | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751158132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128108611 | ||||||||
| FaxNumber: | 5125512567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | J2590 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 127007611 | 05 | TX | MEDICAID | 7600029 | 01 | TX | UNITED HEALTHCARE | OTHER | 127007610 | 05 | TX | MEDICAID | 8G8840 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 127007612 | 05 | TX | MEDICAID | 127007613 | 05 | TX | MEDICAID | 127007614 | 05 | TX | MEDICAID | 9399591007 | 01 | TX | CIGNA | OTHER | 156289401 | 05 | TX | MEDICAID | 2543029 | 01 | TX | AETNA | OTHER | BG1920253 | 01 | TX | DEA NUMBER | OTHER |