Provider Demographics
NPI:1174630230
Name:GUTIERREZ, CONSTANZA J (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANZA
Middle Name:J
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 1:5655 HUDSON DR STE 210
Mailing Address - Street 2:ARIS RADIOLOGY
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4455
Mailing Address - Country:US
Mailing Address - Phone:330-655-1869
Mailing Address - Fax:330-655-3828
Practice Address - Street 1:3801 N LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-4080
Practice Address - Country:US
Practice Address - Phone:512-407-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1219362085R0202X
TXL33242085R0202X
DCMD0376492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00722670OtherRAILROAD MEDICARE
TX147741602OtherCSHCN
TX147741601Medicaid
TX300127291Medicare PIN
DCP00722670OtherRAILROAD MEDICARE
TX147741601Medicaid
DC142486YT2Medicare PIN