Provider Demographics
NPI:1346416864
Name:GUTIERREZ, IVAN MISAEL (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:MISAEL
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:PO BOX 31235
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1235
Mailing Address - Country:US
Mailing Address - Phone:520-324-2308
Mailing Address - Fax:
Practice Address - Street 1:5166 E GLENN ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1337
Practice Address - Country:US
Practice Address - Phone:520-795-5338
Practice Address - Fax:520-795-5382
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ596742086S0120X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program