Provider Demographics
NPI:1376239111
Name:GUTZMER, NICHOLAS ANDREW (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:GUTZMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12430 LIGHTHOUSE WAY DR APT F
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6482
Mailing Address - Country:US
Mailing Address - Phone:816-752-3529
Mailing Address - Fax:
Practice Address - Street 1:2345 DOUGHERTY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3313
Practice Address - Country:US
Practice Address - Phone:314-966-9586
Practice Address - Fax:314-966-9394
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program