Healthcare Provider Details

I. General information

NPI: 1609872118
Provider Name (Legal Business Name): ALBERT RICHARD GUTIERREZ JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12037 CORTEZ BLVD
BROOKSVILLE FL
34613-7349
US

IV. Provider business mailing address

122 LINSLEY AVE STE A
BRANDON FL
33511-5121
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-9008
  • Fax: 352-597-1008
Mailing address:
  • Phone: 813-657-4914
  • Fax: 813-657-4916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME43083
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: