Provider Demographics
NPI:1912908187
Name:GUTIERREZ, SANDRA M (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1026
Mailing Address - Country:US
Mailing Address - Phone:716-508-0575
Mailing Address - Fax:888-275-2338
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:605-698-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25M06801400207Q00000X
NY202625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7875703Medicaid
NJ078749Medicare ID - Type Unspecified
NJH08295Medicare UPIN