Provider Demographics
NPI:1265490122
Name:GUTIERREZ, NEMESIO E
Entity Type:Individual
Prefix:
First Name:NEMESIO
Middle Name:E
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:601 BUSINESS LOOP 70 W
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2546
Practice Address - Country:US
Practice Address - Phone:573-884-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR4H802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO114225OtherBLUE SHIELD/BLUE CHOICE
IL33468547OtherILLINOIS MEDICAID
MO1500107OtherUNITED HEALTHCARE
MO260035875OtherRR MEDICARE
KSK51B502OtherKANSAS MEDICARE
MO202694121Medicaid
MO342200OtherHEALTHLINK
MO342200OtherHEALTHLINK
MO001210635Medicare ID - Type Unspecified