Healthcare Provider Details

I. General information

NPI: 1356339147
Provider Name (Legal Business Name): ALBERT MANUEL GUTIERREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 E FARREL RD
LAFAYETTE LA
70508-7104
US

IV. Provider business mailing address

PO BOX 52843
LAFAYETTE LA
70505-2843
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-9110
  • Fax: 337-981-8485
Mailing address:
  • Phone: 337-981-9110
  • Fax: 337-981-8485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number11023 R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: