=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982879383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORGE G. GUTIERREZ, M.D. A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2008
-----------------------------------------------------
Last Update Date | 04/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 N PALM CANYON DR STE 105
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-320-3383
-----------------------------------------------------
Fax | 760-325-8546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 N PALM CANYON DR STE 105
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-320-3383
-----------------------------------------------------
Fax | 760-325-8546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. VANGIE LARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-320-3383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A312330
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------