Healthcare Provider Details

I. General information

NPI: 1356314504
Provider Name (Legal Business Name): GUTIERREZ MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

IV. Provider business mailing address

1010 E ROOSEVELT AVE
GRANTS NM
87020-2118
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2948
  • Fax: 505-287-5372
Mailing address:
  • Phone: 505-287-2948
  • Fax: 505-287-5372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIA ROMERO
Title or Position: OFFICE MANAGER
Credential: RHIT
Phone: 505-287-2948