Provider Demographics
NPI:1932412871
Name:BAKOTA GUTIERREZ, JILL M (OD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:BAKOTA GUTIERREZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:BAKOTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:MARTIN ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:6600 VAN AALST BLVD, BLDG 9250
Mailing Address - City:FT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MARTIN ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:6600 VAN AALST BLVD, BLDG 9250
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:762-408-3498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8634 TG152W00000X
GAOPT002625152W00000X
CO0002964152W00000X
IL046010341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist