Provider Demographics
NPI:1114082989
Name:GUTRECHT, JOSE A (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:GUTRECHT
Suffix:
Gender:M
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:LAHEY CLINIC
Mailing Address - Street 2:41 MALL RD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8631
Mailing Address - Fax:
Practice Address - Street 1:LAHEY CLINIC
Practice Address - Street 2:41 MALL RD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA471562084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110063844AMedicaid
MA6167527Medicaid
MA130011302Medicare PIN
MAB10023Medicare PIN
MA110063844AMedicaid