Provider Demographics
NPI:1629177514
Name:GUTKNECHT, MICHAEL GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:GUTKNECHT
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 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:239-931-6373
Practice Address - Street 1:3660 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8005
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:239-931-6373
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG97472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
149VCOtherFLORIDA BLUE CROSS
FL02271000Medicaid
FL02271000Medicaid
TX118323804Medicaid