Healthcare Provider Details

I. General information

NPI: 1639311780
Provider Name (Legal Business Name): NESTOR GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 QUAIL CT
DOWNS IL
61736-9323
US

IV. Provider business mailing address

17 QUAIL CT
DOWNS IL
61736-9323
US

V. Phone/Fax

Practice location:
  • Phone: 309-378-3007
  • Fax:
Mailing address:
  • Phone: 309-378-3007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036040782
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: