Provider Demographics
NPI:1619079084
Name:GUTIERREZ, JUAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11880 SW 40TH ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3584
Mailing Address - Country:US
Mailing Address - Phone:305-227-6618
Mailing Address - Fax:305-227-6668
Practice Address - Street 1:11880 SW 40TH ST
Practice Address - Street 2:SUITE 404
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3584
Practice Address - Country:US
Practice Address - Phone:305-227-6618
Practice Address - Fax:305-227-6668
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2015-08-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME40749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068939400Medicaid
FL650119044OtherTAX ID
FL650119044OtherTAX ID
FL068939400Medicaid
FL96185Medicare PIN