Provider Demographics
NPI:1255330718
Name:GUTIERREZ, ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
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 1:755 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7497
Mailing Address - Country:US
Mailing Address - Phone:717-273-6706
Mailing Address - Fax:717-273-1435
Practice Address - Street 1:755 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7497
Practice Address - Country:US
Practice Address - Phone:717-273-6706
Practice Address - Fax:717-273-1435
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428609207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1552372OtherGATEWAY
PA50058270OtherCAPITAL BLUE CROSS
PA1015455900001Medicaid
PAGU136434OtherHIGHMARK BLUE SHIELD
PA1552372OtherGATEWAY
PA50058270OtherCAPITAL BLUE CROSS