Healthcare Provider Details

I. General information

NPI: 1225371354
Provider Name (Legal Business Name): JACQUELINE GUTERMAN MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 CROMWELL AVE
STATEN ISLAND NY
10304-3912
US

IV. Provider business mailing address

24 DOROTHY ST
STATEN ISLAND NY
10314
US

V. Phone/Fax

Practice location:
  • Phone: 718-987-9175
  • Fax: 718-987-1322
Mailing address:
  • Phone: 917-679-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number287666
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: