Healthcare Provider Details

I. General information

NPI: 1164696555
Provider Name (Legal Business Name): PEDRO M GUTIERREZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 NORTH AVE
ELIZABETH NJ
07208-1738
US

IV. Provider business mailing address

464 NORTH AVE
ELIZABETH NJ
07208-1738
US

V. Phone/Fax

Practice location:
  • Phone: 908-351-0790
  • Fax: 908-355-5966
Mailing address:
  • Phone: 908-351-0790
  • Fax: 908-355-5966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: PEDRO M GUTIERREZ
Title or Position: OWNER
Credential:
Phone: 908-351-0790