Provider Demographics
NPI:1285624155
Name:GUIMARAES, PEDRO DEOLIVEIRA (MD)
Entity type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:DEOLIVEIRA
Last Name:GUIMARAES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PEDRO
Other - Middle Name:DE OLIVEIRA
Other - Last Name:GUIMARAES NETO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 14209
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-4209
Mailing Address - Country:US
Mailing Address - Phone:805-540-0279
Mailing Address - Fax:805-439-1070
Practice Address - Street 1:1329 BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3909
Practice Address - Country:US
Practice Address - Phone:805-540-0279
Practice Address - Fax:805-439-1070
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2165162084P0800X
CAC520932084P0800X
ME0137612084P0800X
NH134282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF48906Medicare UPIN
MEMM5736Medicare ID - Type UnspecifiedMEDICARE B