Provider Demographics
NPI:1669449773
Name:GUTIERREZ-GO, M. NIEVES EUSEBIO (MD)
Entity Type:Individual
Prefix:DR
First Name:M. NIEVES
Middle Name:EUSEBIO
Last Name:GUTIERREZ-GO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80495 US HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6534
Mailing Address - Country:US
Mailing Address - Phone:760-347-2887
Mailing Address - Fax:760-347-0776
Practice Address - Street 1:80495 US HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6534
Practice Address - Country:US
Practice Address - Phone:760-347-2887
Practice Address - Fax:760-347-0776
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51819208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF84948Medicare UPIN