Healthcare Provider Details

I. General information

NPI: 1528032109
Provider Name (Legal Business Name): JOSE A GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S DOBSON RD ATTN: PEDIATRIC INTENSIVE CARE UNIT
MESA AZ
85202-4707
US

IV. Provider business mailing address

1334 W DEER CREEK RD
PHOENIX AZ
85045-0753
US

V. Phone/Fax

Practice location:
  • Phone: 480-412-3340
  • Fax:
Mailing address:
  • Phone: 480-412-3340
  • Fax: 480-460-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number25242
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier385501
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: