Provider Demographics
NPI:1982879383
Name:JORGE G. GUTIERREZ, M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JORGE G. GUTIERREZ, M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-320-3383
Mailing Address - Street 1:1100 N PALM CANYON DR
Mailing Address - Street 2:STE 105
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4414
Mailing Address - Country:US
Mailing Address - Phone:760-320-3383
Mailing Address - Fax:760-325-8546
Practice Address - Street 1:1100 N PALM CANYON DR
Practice Address - Street 2:STE 105
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4414
Practice Address - Country:US
Practice Address - Phone:760-320-3383
Practice Address - Fax:760-325-8546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA312330174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26398Medicare UPIN
CA00A312330Medicare PIN