Provider Demographics
NPI:1356346373
Name:GUTIERREZ, REINALDO M JR (MD)
Entity type:Individual
Prefix:DR
First Name:REINALDO
Middle Name:M
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 1:380 SOUTH OYSTER BAY ROAD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801
Mailing Address - Country:US
Mailing Address - Phone:516-942-3330
Mailing Address - Fax:516-942-3334
Practice Address - Street 1:380 S OYSTER BAY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3509
Practice Address - Country:US
Practice Address - Phone:516-942-3330
Practice Address - Fax:516-942-3334
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210965207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02020708Medicaid
NYG68753Medicare UPIN
NY794621Medicare ID - Type Unspecified