Provider Demographics
NPI:1649210659
Name:GUTTUSO, PAUL A (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:GUTTUSO
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 1:604 S 3RD ST STE A
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75147-2727
Mailing Address - Country:US
Mailing Address - Phone:903-887-1073
Mailing Address - Fax:903-887-0496
Practice Address - Street 1:604 S 3RD ST STE A
Practice Address - Street 2:
Practice Address - City:MABANK
Practice Address - State:TX
Practice Address - Zip Code:75147-2727
Practice Address - Country:US
Practice Address - Phone:903-887-1073
Practice Address - Fax:903-887-0496
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5546207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144327702Medicaid
TX144327703Medicaid
TX144327704Medicaid
TX144327702Medicaid
TX8L12153Medicare PIN
TX8D2462Medicare PIN
H31605Medicare UPIN