Provider Demographics
NPI:1720260060
Name:JOHN C GUTLEBER MD PA
Entity Type:Organization
Organization Name:JOHN C GUTLEBER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GUTLEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-247-1213
Mailing Address - Street 1:139 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4508
Mailing Address - Country:US
Mailing Address - Phone:305-247-1213
Mailing Address - Fax:
Practice Address - Street 1:139 NE 15TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-4508
Practice Address - Country:US
Practice Address - Phone:305-247-1213
Practice Address - Fax:305-247-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70290174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002435404OtherUNITED HEALTH CARE
FL1012734OtherCAREPLUS
FL279472OtherAVMED
FL31716OtherBCBS
FL245462OtherWELLCARE
FL250356500Medicaid
FL43136OtherNEIGHBORHOOD HEALTH
FL591593951OtherSTAYWELL
FL245462OtherHEALTHEASE
FL7466251OtherAETNA
FL591593951OtherSTAYWELL
FL=========OtherCIGNA
FL7466251OtherAETNA