Healthcare Provider Details

I. General information

NPI: 1588634919
Provider Name (Legal Business Name): ANDRES IVAN GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 RD KM 0.9 CANDELARIA
LAJAS PR
00667-0596
US

IV. Provider business mailing address

PO BOX 596
LAJAS PR
00667-0596
US

V. Phone/Fax

Practice location:
  • Phone: 787-899-3928
  • Fax: 787-899-3928
Mailing address:
  • Phone: 787-899-3928
  • Fax: 787-899-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15879
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: