Provider Demographics
NPI:1245402601
Name:GUTIERREZ, VINCENT DAVID (PT)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:DAVID
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18215 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3609
Mailing Address - Country:US
Mailing Address - Phone:708-444-2563
Mailing Address - Fax:708-444-2769
Practice Address - Street 1:18215 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3609
Practice Address - Country:US
Practice Address - Phone:708-444-2563
Practice Address - Fax:708-444-2769
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist