Provider Demographics
NPI:1740238468
Name:GUTIERREZ, BERNARDO A (MD)
Entity Type:Individual
Prefix:
First Name:BERNARDO
Middle Name:A
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:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-533-6837
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:14075 TOWN LOOP BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6132
Practice Address - Country:US
Practice Address - Phone:407-438-5858
Practice Address - Fax:407-387-1724
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME141745207R00000X, 207R00000X, 207R00000X
SC26615207R00000X
TXJ5778207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLZ370OtherMEDICARE
FL104818600Medicaid
SC2776963OtherCIGNA
SC266152Medicaid
SC576007863115OtherBCBS OF SC
SCP00136499OtherRR MEDICARE
SC2776963OtherCIGNA
SCD168223640Medicare PIN