Provider Demographics
NPI:1396029641
Name:GUTIERREZ, RICARDO (SOIDC)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BOYSENBERRY LN
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539
Mailing Address - Country:US
Mailing Address - Phone:910-577-1621
Mailing Address - Fax:
Practice Address - Street 1:400 BOYSENBERRY LN
Practice Address - Street 2:
Practice Address - City:HUBERT
Practice Address - State:NC
Practice Address - Zip Code:28539
Practice Address - Country:US
Practice Address - Phone:910-577-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman