Provider Demographics
NPI:1750519070
Name:GUTIERREZ, JENNIFER S (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:FELISILDA
Other - Last Name:SUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3600 MINNESOTA DR STE 800
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-7915
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:3600 MINNESOTA DR STE 800
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-7915
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012553072085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC185R7OtherBCBSNC
VA10121709OtherOPTIMA HEALTH PLAN
VA4787799OtherAETNA HEALTHCARE
VA1750519070Medicaid
VAVVC608AMedicare PIN
VA10121709OtherSENTARA HEALTH PALN
VA139178OtherBCBSVA
VA1750519070OtherVIRGINIA PREMIER HEALTH PLAN
VAP01293587OtherRAILROAD MEDICARE
NC1750519070Medicaid