Basic Information
Provider Information | |||||||||
NPI: | 1780664631 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUANZON | ||||||||
FirstName: | MARIE DENISE | ||||||||
MiddleName: | ALFONSO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 SIXTH AVE N | ||||||||
Address2: | CENTRACARE CLINIC | ||||||||
City: | ST CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015307000 | ||||||||
FaxNumber: | 7015308842 | ||||||||
Practice Location | |||||||||
Address1: | 1200 SIXTH AVE N | ||||||||
Address2: | CENTRACARE CLINIC | ||||||||
City: | ST CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015307000 | ||||||||
FaxNumber: | 7015308842 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2006 | ||||||||
LastUpdateDate: | 04/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 9430 | ND | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 53336 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207K00000X | 53336 | MN | N |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | 13077 | 05 | ND |   | MEDICAID | P00327845 | 01 | ND | RR MEDICARE | OTHER |