Provider Demographics
NPI:1164522769
Name:GUTIERREZ, SALVADOR RODOLFO III (MD)
Entity Type:Individual
Prefix:MR
First Name:SALVADOR
Middle Name:RODOLFO
Last Name:GUTIERREZ
Suffix:III
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 1:109 POPLAR CT
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1035
Mailing Address - Country:US
Mailing Address - Phone:847-564-4836
Mailing Address - Fax:
Practice Address - Street 1:2655 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1643
Practice Address - Country:US
Practice Address - Phone:773-489-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036087656Medicaid
01634265OtherBCBS
IL1710175880OtherORG. NPI
ILF32805Medicare UPIN