Provider Demographics
NPI:1902878044
Name:GUTIERREZ, RICARDO JR (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:GUTIERREZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 E 29TH ST
Mailing Address - Street 2:STE 220
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802
Mailing Address - Country:US
Mailing Address - Phone:979-774-4008
Mailing Address - Fax:979-774-7893
Practice Address - Street 1:2700 E 29TH ST
Practice Address - Street 2:STE 220
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802
Practice Address - Country:US
Practice Address - Phone:979-774-4008
Practice Address - Fax:979-774-7893
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7751207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127482106Medicaid
TX8B6974Medicare ID - Type Unspecified
TX127482106Medicaid