Provider Demographics
NPI:1174603468
Name:GUIDA, JACQUELYN (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:GUIDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CLEVELAND PL
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6326
Mailing Address - Country:US
Mailing Address - Phone:516-541-3432
Mailing Address - Fax:
Practice Address - Street 1:542 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1829
Practice Address - Country:US
Practice Address - Phone:516-679-5866
Practice Address - Fax:516-679-5869
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005946-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02439985Medicaid
NYU98410Medicare UPIN
NYC308D1Medicare ID - Type Unspecified