Provider Demographics
NPI:1710901004
Name:GUTIERREZ, ANACLETO (OD)
Entity Type:Individual
Prefix:
First Name:ANACLETO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5904
Mailing Address - Country:US
Mailing Address - Phone:916-447-2020
Mailing Address - Fax:916-447-2910
Practice Address - Street 1:2615 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5904
Practice Address - Country:US
Practice Address - Phone:916-447-2020
Practice Address - Fax:916-447-2910
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5532TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0747430001OtherDMERC SUPPLIER #
CAGSD0015301OtherMEDI-CAL GROUP #
CASD0055320Medicaid
CAZZZ17944ZOtherMEDICARE GROUP#
CA0747430001OtherDMERC SUPPLIER #
CASD0055320Medicare ID - Type Unspecified