Provider Demographics
NPI:1376678110
Name:OCTAVIO E. GUTIERREZ, M.D., P.A.
Entity Type:Organization
Organization Name:OCTAVIO E. GUTIERREZ, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD, ADOLESCENT, ADULT PSYCHIATRY
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:E
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:915-562-1202
Mailing Address - Street 1:PO BOX 972777
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79997-2777
Mailing Address - Country:US
Mailing Address - Phone:915-562-1202
Mailing Address - Fax:915-599-1414
Practice Address - Street 1:1600 N LEE TREVINO DR STE D2
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5164
Practice Address - Country:US
Practice Address - Phone:915-562-1202
Practice Address - Fax:915-599-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE43752084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128-487-901Medicaid
TXP000KK726Medicare ID - Type Unspecified
TX128-487-901Medicaid