Provider Demographics
NPI:1811417066
Name:GUTMAN, ILYA
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:GUTMAN
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 1:1211 UNION AVE STE 520
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6656
Mailing Address - Country:US
Mailing Address - Phone:901-448-5879
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVENUE SUITE 447
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-1932
Practice Address - Country:US
Practice Address - Phone:901-759-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program