Provider Demographics
NPI:1659389971
Name:GUTIERREZ, J SANTIAG (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:SANTIAG
Last Name: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 1:6930 SPRINGFIELD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-2262
Mailing Address - Country:US
Mailing Address - Phone:956-725-8484
Mailing Address - Fax:956-724-8459
Practice Address - Street 1:6930 SPRINGFIELD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-2262
Practice Address - Country:US
Practice Address - Phone:956-725-8484
Practice Address - Fax:956-724-8459
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9746207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099792601Medicaid
TXC16404Medicare UPIN
TX00QD48Medicare PIN