Provider Demographics
NPI:1831295955
Name:GUTIERREZ, MARIO (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5212 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5712
Mailing Address - Country:US
Mailing Address - Phone:210-829-8083
Mailing Address - Fax:210-822-4011
Practice Address - Street 1:5212 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5712
Practice Address - Country:US
Practice Address - Phone:210-829-8083
Practice Address - Fax:210-822-4011
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3345TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135221306Medicaid
TX135221306Medicaid
TXT86689Medicare UPIN