Provider Demographics
NPI:1750852505
Name:GUTIERREZ, IMER
Entity Type:Individual
Prefix:
First Name:IMER
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 NE 4TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4268
Mailing Address - Country:US
Mailing Address - Phone:541-306-4446
Mailing Address - Fax:541-550-2011
Practice Address - Street 1:125 SW C ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1458
Practice Address - Country:US
Practice Address - Phone:541-306-4566
Practice Address - Fax:541-320-9005
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-CRM-382175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist