Healthcare Provider Details

I. General information

NPI: 1629209366
Provider Name (Legal Business Name): ILITCH DIAZ GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BEAM AVE STE 302
MAPLEWOOD MN
55109-1477
US

IV. Provider business mailing address

3144 CHOWEN AVE S APT 219B
MINNEAPOLIS MN
55416-5398
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-6351
  • Fax:
Mailing address:
  • Phone: 505-818-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberRS2009-0378
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number63088
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: