Healthcare Provider Details

I. General information

NPI: 1235134834
Provider Name (Legal Business Name): RENE S GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 E MARKET ST
LOGANSPORT IN
46947-2295
US

IV. Provider business mailing address

3400 E MARKET ST
LOGANSPORT IN
46947-2295
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-9633
  • Fax: 574-722-5987
Mailing address:
  • Phone: 574-722-9633
  • Fax: 574-722-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01042516
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: