Provider Demographics
NPI:1144336389
Name:GUTIERREZ, MARIO A MD PA
Entity type:Organization
Organization Name:GUTIERREZ, MARIO A MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-625-0977
Mailing Address - Street 1:313 W. COUNTRY CLUB RD
Mailing Address - Street 2:STE 14
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:575-625-0977
Mailing Address - Fax:575-625-1027
Practice Address - Street 1:313 W. COUNTRY CLUB RD
Practice Address - Street 2:STE 14
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201
Practice Address - Country:US
Practice Address - Phone:575-625-0977
Practice Address - Fax:575-625-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-213207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME1358Medicaid
F03920Medicare UPIN