Provider Demographics
NPI:1184136079
Name:GUTALJ, ALEKSANDAR (CAA)
Entity type:Individual
Prefix:
First Name:ALEKSANDAR
Middle Name:
Last Name:GUTALJ
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8681 A C SKINNER PKWY APT 123
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0841
Mailing Address - Country:US
Mailing Address - Phone:904-616-3374
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-387-4030
Practice Address - Fax:904-616-3374
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA438207L00000X, 367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA438OtherFLORIDA BOARD OF MEDICINE MEDICAL LICENSE