Provider Demographics
NPI:1912999301
Name:GUTIERREZ, GUILLERMO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
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:PO BOX 48270
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-8470
Mailing Address - Country:US
Mailing Address - Phone:201-818-9118
Mailing Address - Fax:
Practice Address - Street 1:530 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3654
Practice Address - Country:US
Practice Address - Phone:732-324-6031
Practice Address - Fax:732-324-4811
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05749600208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2490711000OtherAMERIHEALTH ID#
NJ271940OtherAMERIGROUP ID#
NJ8220018OtherGHI PPO
NJP00211038OtherRAILROAD MEDICARE#
NJ60012743OtherHORIZON NJ HEALTH#
NJ39302OtherUHP ID#
NJ3K3773OtherHEALTHNET #
NJP00211038OtherRAILROAD MEDICARE#
NJ8220018OtherGHI PPO