Healthcare Provider Details

I. General information

NPI: 1568698090
Provider Name (Legal Business Name): JUAN RAUL GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 INTERNATIONAL AVE.
OAKLAND CA
94606-3730
US

IV. Provider business mailing address

1601 FRUITVALE AVE.
OAKLAND CA
94601
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-5001
  • Fax: 415-476-4009
Mailing address:
  • Phone: 510-535-4000
  • Fax: 510-535-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA108242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: