Provider Demographics
NPI:1659451193
Name:GUTIERREZ, OCTAVIO E (MD, PA)
Entity type:Individual
Prefix:DR
First Name:OCTAVIO
Middle Name:E
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:MD, PA
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 972777
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79997
Mailing Address - Country:US
Mailing Address - Phone:915-204-2299
Mailing Address - Fax:
Practice Address - Street 1:1600 N LEE TREVINO
Practice Address - Street 2:C-4
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-204-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE43752084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC16410Medicare UPIN
TXP000KK726Medicare ID - Type UnspecifiedMEDICARE NUMBER
TX128-487-901Medicaid