Provider Demographics
NPI:1508496126
Name:GUTIERREZ, MARC R
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:R
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E APPLE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2902
Mailing Address - Country:US
Mailing Address - Phone:937-257-9926
Mailing Address - Fax:
Practice Address - Street 1:128 E APPLE ST FL 2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2902
Practice Address - Country:US
Practice Address - Phone:937-257-9926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program