Healthcare Provider Details

I. General information

NPI: 1396998977
Provider Name (Legal Business Name): OMAR DE JESUS GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 MARVEL ST
COUSHATTA LA
71019-9022
US

IV. Provider business mailing address

1635 MARVEL ST
COUSHATTA LA
71019-9022
US

V. Phone/Fax

Practice location:
  • Phone: 318-932-2000
  • Fax:
Mailing address:
  • Phone: 318-932-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-14401
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number250840
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number324278
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number250840-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: