Healthcare Provider Details

I. General information

NPI: 1831281070
Provider Name (Legal Business Name): NICASIO S GUTIERREZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 ALAMEDA ST
NORMAN OK
73071-5229
US

IV. Provider business mailing address

3616 WINDOVER DR
NORMAN OK
73072-3249
US

V. Phone/Fax

Practice location:
  • Phone: 405-573-3558
  • Fax: 405-573-3962
Mailing address:
  • Phone: 405-321-7388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number14904
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: