Provider Demographics
NPI:1427444587
Name:GUILLERMO, JESUS TEDDY ESTAVILLO (IDC)
Entity type:Individual
Prefix:
First Name:JESUS TEDDY
Middle Name:ESTAVILLO
Last Name:GUILLERMO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20094
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0094
Mailing Address - Country:US
Mailing Address - Phone:910-451-3607
Mailing Address - Fax:
Practice Address - Street 1:PSC BOX 20094
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0094
Practice Address - Country:US
Practice Address - Phone:910-451-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman