Provider Demographics
NPI:1093987000
Name:GUTIERREZ, BERTHA PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:PATRICIA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:312-699-5841
Mailing Address - Fax:312-491-5485
Practice Address - Street 1:5647 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:773-736-1830
Practice Address - Fax:773-736-1840
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123675207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036123675Medicaid
IL324020009Medicare Oscar/Certification