Provider Demographics
NPI:1124214218
Name:GUTIERREZ SANTIAGO, JESSICA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:GUTIERREZ SANTIAGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GUTIERREZ SANTIAGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1651 N SEMORAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-3575
Mailing Address - Country:US
Mailing Address - Phone:407-249-1234
Mailing Address - Fax:
Practice Address - Street 1:1601 PARK CENTER DR STE 6B
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5700
Practice Address - Country:US
Practice Address - Phone:407-249-1234
Practice Address - Fax:407-249-1755
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11742 I208000000X
PR17851208000000X
FLME112748208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009358300Medicaid