Provider Demographics
NPI:1902893290
Name:GUARDERAS, JUAN C (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:GUARDERAS
Suffix:
Gender:M
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 3068
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3068
Mailing Address - Country:US
Mailing Address - Phone:229-247-1667
Mailing Address - Fax:229-245-7661
Practice Address - Street 1:3334 GREYSTONE WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1096
Practice Address - Country:US
Practice Address - Phone:229-247-1667
Practice Address - Fax:229-245-7661
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80320207KA0200X, 207K00000X
FLME62732207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261325500Medicaid
GA000892966AMedicaid
FL18056OtherBLUE CROSS/BLUE SHIELD
FL030002009OtherRAILROAD MEDICARE
GA000892966AMedicaid
FL261325500Medicaid