Provider Demographics
NPI:1093880239
Name:GUTIERREZ, PEDRO M
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07207-1738
Mailing Address - Country:US
Mailing Address - Phone:908-351-0790
Mailing Address - Fax:908-355-5966
Practice Address - Street 1:464 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1738
Practice Address - Country:US
Practice Address - Phone:908-351-0790
Practice Address - Fax:908-355-5966
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04127900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6507403Medicaid
NJC53808Medicare UPIN
NJ180681Medicare PIN
NJ6507403Medicaid
NJC53807Medicare UPIN