Provider Demographics
NPI:1457643033
Name:GUTIERREZ, NICHOLAS MARK (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:MARK
Last Name:GUTIERREZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E MOREHEAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2624 DAWSON RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-1609
Practice Address - Country:US
Practice Address - Phone:229-888-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1257202085R0202X
GA1018022085R0202X
FL1257202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology