Provider Demographics
NPI:1912158122
Name:GUTIERREZ, EULOGIO QUINTOS (IDC)
Entity Type:Individual
Prefix:MR
First Name:EULOGIO
Middle Name:QUINTOS
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7293 BIRCH CIR
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-4501
Mailing Address - Country:US
Mailing Address - Phone:951-775-3895
Mailing Address - Fax:
Practice Address - Street 1:1058 MIDDAUGH STREET
Practice Address - Street 2:
Practice Address - City:KANEOHE BAY
Practice Address - State:HI
Practice Address - Zip Code:96863
Practice Address - Country:US
Practice Address - Phone:808-257-1479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman