Provider Demographics
NPI:1356339147
Name:GUTIERREZ, ALBERT MANUEL (MD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:MANUEL
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:PO BOX 52843
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2843
Mailing Address - Country:US
Mailing Address - Phone:337-981-9110
Mailing Address - Fax:337-981-8485
Practice Address - Street 1:208 E FARREL RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7104
Practice Address - Country:US
Practice Address - Phone:337-981-9110
Practice Address - Fax:337-981-8485
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11023 R2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1659681Medicaid
F15913Medicare UPIN
LA5W102Medicare ID - Type Unspecified