Healthcare Provider Details

I. General information

NPI: 1376239111
Provider Name (Legal Business Name): NICHOLAS ANDREW GUTZMER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 DOUGHERTY FERRY RD
SAINT LOUIS MO
63122-3313
US

IV. Provider business mailing address

12430 LIGHTHOUSE WAY DR APT F
SAINT LOUIS MO
63141-6482
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-9586
  • Fax: 314-966-9394
Mailing address:
  • Phone: 816-752-3529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: