Healthcare Provider Details

I. General information

NPI: 1336315902
Provider Name (Legal Business Name): M. NIEVES GUTIERREZ-GO, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80495 US HIGHWAY 111
INDIO CA
92201-6534
US

IV. Provider business mailing address

80495 US HIGHWAY 111
INDIO CA
92201-6534
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-2887
  • Fax: 760-347-0776
Mailing address:
  • Phone: 760-347-2887
  • Fax: 760-347-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA51819
License Number StateCA

VIII. Authorized Official

Name: M. NIEVES GUTIERREZ-GO
Title or Position: PRESIDENT
Credential:
Phone: 760-347-2887