Provider Demographics
NPI:1396998977
Name:GUTIERREZ, OMAR DE JESUS (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:DE JESUS
Last Name:GUTIERREZ
Suffix:
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 1:1635 MARVEL ST
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019-9022
Mailing Address - Country:US
Mailing Address - Phone:318-932-2000
Mailing Address - Fax:
Practice Address - Street 1:1635 MARVEL ST
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9022
Practice Address - Country:US
Practice Address - Phone:318-932-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-14401207Q00000X
NY250840208600000X
LA324278207Q00000X
NY250840-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2540483Medicaid
AR251109001Medicaid