Provider Demographics
NPI:1134742182
Name:GUTIERREZ MENDIOLA, ANTONIO ENRIQUE (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:ENRIQUE
Last Name:GUTIERREZ MENDIOLA
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 1:11460 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-4128
Mailing Address - Country:US
Mailing Address - Phone:786-925-4234
Mailing Address - Fax:
Practice Address - Street 1:11460 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4128
Practice Address - Country:US
Practice Address - Phone:954-874-5526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR36271R1835P0018X
PR390200000X
FLME168251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program