Provider Demographics
NPI:1881629624
Name:GUTIERREZ, MIGUEL A (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
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 1:1517 TEXAS DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-6327
Mailing Address - Country:US
Mailing Address - Phone:817-458-3300
Mailing Address - Fax:817-458-3370
Practice Address - Street 1:1517 TEXAS DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6327
Practice Address - Country:US
Practice Address - Phone:817-458-3300
Practice Address - Fax:817-458-3370
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148305902Medicaid
TX148305904Medicaid
TX148305902Medicaid