=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447568639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS ANTONIO GUTIERREZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2010
-----------------------------------------------------
Last Update Date | 09/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 CAMPINDIAN HEAD RD.
-----------------------------------------------------
City | LAND O' LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34634-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-948-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 CAMPINDIAN HEAD RD.
-----------------------------------------------------
City | LAND O' LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34634-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-948-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | 15112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------