Provider Demographics
NPI:1528032109
Name:GUTIERREZ, JOSE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
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 1:1334 W DEER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0753
Mailing Address - Country:US
Mailing Address - Phone:480-412-3340
Mailing Address - Fax:480-460-3632
Practice Address - Street 1:1400 S DOBSON RD
Practice Address - Street 2:ATTN: PEDIATRIC INTENSIVE CARE UNIT
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4707
Practice Address - Country:US
Practice Address - Phone:480-412-3340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ252422080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ385501Medicaid
AZ385501Medicaid
65661Medicare ID - Type Unspecified
G38745Medicare UPIN