Provider Demographics
NPI:1629209366
Name:DIAZ GUTIERREZ, ILITCH (MD)
Entity Type:Individual
Prefix:
First Name:ILITCH
Middle Name:
Last Name:DIAZ 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 1:3144 CHOWEN AVE S
Mailing Address - Street 2:APT 219B
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5398
Mailing Address - Country:US
Mailing Address - Phone:505-818-7180
Mailing Address - Fax:
Practice Address - Street 1:1655 BEAM AVE STE 302
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1477
Practice Address - Country:US
Practice Address - Phone:651-227-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2009-0378208600000X
MN63088208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery