Provider Demographics
NPI:1790273761
Name:GUTIERREZ, OMAR (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
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 1:822 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1594
Mailing Address - Country:US
Mailing Address - Phone:937-344-1586
Mailing Address - Fax:
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:937-344-1586
Practice Address - Fax:304-949-8731
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.144411207R00000X
OH39207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH39Medicaid