Provider Demographics
NPI:1255356283
Name:GUTIERREZ, LARA (OD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 W 62ND ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4619
Mailing Address - Country:US
Mailing Address - Phone:773-327-3000
Mailing Address - Fax:773-327-3015
Practice Address - Street 1:1730 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1900
Practice Address - Country:US
Practice Address - Phone:773-327-3000
Practice Address - Fax:773-327-3015
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist