Provider Demographics
NPI:1104211812
Name:GUTIERREZ, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 W 8TH ST # L18
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-383-1003
Mailing Address - Fax:904-244-7388
Practice Address - Street 1:653 W 8TH ST # L18
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-383-1003
Practice Address - Fax:904-244-7388
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME136391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program