Healthcare Provider Details

I. General information

NPI: 1114549938
Provider Name (Legal Business Name): DR. CARLOS MANUEL GUTIERREZ MENDIOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 W HILLSBORO BLVD STE A
DEERFIELD BEACH FL
33442-1421
US

IV. Provider business mailing address

900 VILLAGE SQUARE XING STE 210
PALM BEACH GARDENS FL
33410-4550
US

V. Phone/Fax

Practice location:
  • Phone: 954-426-3494
  • Fax:
Mailing address:
  • Phone: 239-313-2517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberME167551
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: