Healthcare Provider Details

I. General information

NPI: 1184647901
Provider Name (Legal Business Name): MR. JOSE R GUTIERREZ COLON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 7722 KM 5.6 LA SIERRA BOX 622
AIBONITO PR
00705-0622
US

IV. Provider business mailing address

PO BOX 622
AIBONITO PR
00705-0622
US

V. Phone/Fax

Practice location:
  • Phone: 787-735-7129
  • Fax: 787-735-1679
Mailing address:
  • Phone: 787-735-7129
  • Fax: 787-735-1679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberTC AMB 230
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: