Provider Demographics
NPI:1992866008
Name:GUTIERREZ, WALDO ANTONIO (PT)
Entity Type:Individual
Prefix:MR
First Name:WALDO
Middle Name:ANTONIO
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3462 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1720
Mailing Address - Country:US
Mailing Address - Phone:361-854-9741
Mailing Address - Fax:361-854-9742
Practice Address - Street 1:3462 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1720
Practice Address - Country:US
Practice Address - Phone:361-854-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1077394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX650566Medicare ID - Type Unspecified