Provider Demographics
NPI:1346382215
Name:GUTIERREZ, IDA G (MPT)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:G
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7109 N BARTLETT AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6473
Mailing Address - Country:US
Mailing Address - Phone:956-727-2122
Mailing Address - Fax:956-727-4445
Practice Address - Street 1:7109 N BARTLETT AVE STE 109
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6473
Practice Address - Country:US
Practice Address - Phone:956-727-2122
Practice Address - Fax:956-727-4445
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1114338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB122918Medicare UPIN