Healthcare Provider Details

I. General information

NPI: 1649200734
Provider Name (Legal Business Name): GUILLERMO A GUTIERREZ-CALLEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 N 24TH ST SUITE 150
PHOENIX AZ
85016-4800
US

IV. Provider business mailing address

4722 N 24TH ST SUITE 150
PHOENIX AZ
85016-4800
US

V. Phone/Fax

Practice location:
  • Phone: 602-256-4628
  • Fax: 602-957-9438
Mailing address:
  • Phone: 602-256-4628
  • Fax: 602-957-9438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16667
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number16667
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: