Provider Demographics
NPI:1417975889
Name:GUTIERREZ, GLENN BUENAVENTURA (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:BUENAVENTURA
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 1:267 BOSTON RD.
Mailing Address - Street 2:SUITE 20
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862
Mailing Address - Country:US
Mailing Address - Phone:978-663-6666
Mailing Address - Fax:978-663-6716
Practice Address - Street 1:267 BOSTON RD.
Practice Address - Street 2:SUITE 20
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01862
Practice Address - Country:US
Practice Address - Phone:978-663-6666
Practice Address - Fax:978-663-6716
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110049234AMedicaid
MAE62826Medicare UPIN
MA110049234AMedicaid