Provider Demographics
NPI:1235134834
Name:GUTIERREZ, RENE S (MD)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:S
Last Name:GUTIERREZ
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 1:3400 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-2295
Mailing Address - Country:US
Mailing Address - Phone:574-722-9633
Mailing Address - Fax:574-722-5987
Practice Address - Street 1:3400 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-2295
Practice Address - Country:US
Practice Address - Phone:574-722-9633
Practice Address - Fax:574-722-5987
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200010560Medicaid
IN000000799590OtherANTHEM
INP01167875OtherRR MEDICARE
IN000000799590OtherANTHEM
INF67660Medicare UPIN
IN940067006Medicare PIN