MEDICARE: JACK H GUTMAN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	20A4188	CA

General Provider Information

NPI Number	:	1578609160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK H GUTMAN D.O.

Provider Business Mailing Address
First Line	:	6200 E CANYON RIM RD
Second Line	:	STE 105B
City	:	ANAHEIM
State	:	CA
Zip	:	92807-4317
Country	:	US
Telephone Number	:	714-998-3627
Fax Number	:

Provider Business Practice Location Address
First Line	:	6200 E CANYON RIM RD
Second Line	:	STE 105B
City	:	ANAHEIM
State	:	CA
Zip	:	92807-4317
Country	:	US
Telephone Number	:	714-998-3627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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