Healthcare Provider Details

I. General information

NPI: 1093863029
Provider Name (Legal Business Name): LORAINE MERAZ GUTIERREZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 FAIRMOUNT AVE FAMILY PRACTICE DEPARTMENT
SAN DIEGO CA
92105-1608
US

IV. Provider business mailing address

4060 FAIRMOUNT AVE
SAN DIEGO CA
92105-1608
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-9155
  • Fax: 619-795-9849
Mailing address:
  • Phone: 619-584-1612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG64798
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: