Provider Demographics
NPI:1578933479
Name:GUTIERREZ, RUBEN MARK
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:MARK
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 1:4928 COUNTRY FOREST LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-3933
Mailing Address - Country:US
Mailing Address - Phone:254-315-4655
Mailing Address - Fax:
Practice Address - Street 1:915 W EXCHANGE PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-7017
Practice Address - Country:US
Practice Address - Phone:214-547-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2105529225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant