Provider Demographics
NPI:1780671073
Name:GUTIERREZ, CARMEN REZA (OD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:REZA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:M
Other - Last Name:REZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:364 E ROWLAND ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3154
Mailing Address - Country:US
Mailing Address - Phone:626-331-6448
Mailing Address - Fax:626-967-7006
Practice Address - Street 1:364 E ROWLAND ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3154
Practice Address - Country:US
Practice Address - Phone:626-331-6448
Practice Address - Fax:626-967-7006
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8569T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U11000Medicare UPIN