Healthcare Provider Details

I. General information

NPI: 1366595605
Provider Name (Legal Business Name): ERNESTO GUTIERREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 S CAMPBELL AVE BLDG 2
GREEN VALLEY AZ
85614-0502
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-407-5400
  • Fax: 520-407-5990
Mailing address:
  • Phone: 520-818-3616
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16627
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: