Healthcare Provider Details

I. General information

NPI: 1689930455
Provider Name (Legal Business Name): JONATHAN GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 MERIT DR STE 1500
DALLAS TX
75251-2235
US

IV. Provider business mailing address

6909 CINNABAR DR
FRISCO TX
75035-2177
US

V. Phone/Fax

Practice location:
  • Phone: 214-217-1911
  • Fax:
Mailing address:
  • Phone: 919-946-0932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberQ3371
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA139105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: