Healthcare Provider Details

I. General information

NPI: 1528638731
Provider Name (Legal Business Name): DOMINIQUE JAY GUTIERREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 NAPIER AVE
SAINT JOSEPH MI
49085-2112
US

IV. Provider business mailing address

50 INDUSTRIAL PARK RD
BANGOR MI
49013-1246
US

V. Phone/Fax

Practice location:
  • Phone: 269-982-4941
  • Fax:
Mailing address:
  • Phone: 855-869-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301518252
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: