Healthcare Provider Details

I. General information

NPI: 1790758571
Provider Name (Legal Business Name): KARL R GUTIERREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/09/2007
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 Number79-171
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: