Provider Demographics
NPI:1750741070
Name:GUTIERREZ, JOHNNY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-5711
Mailing Address - Country:US
Mailing Address - Phone:626-316-8309
Mailing Address - Fax:
Practice Address - Street 1:3875 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062
Practice Address - Country:US
Practice Address - Phone:323-290-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA93261564A05217Medicare PIN