1306833918 NPI number — MONIQUE GUTIERREZ M.D.

Table of content: MONIQUE GUTIERREZ M.D. (NPI 1306833918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306833918 NPI number — MONIQUE GUTIERREZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
MONIQUE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306833918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97123-4084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-640-2757
Provider Business Mailing Address Fax Number:
503-640-9753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97123-4084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-640-2757
Provider Business Practice Location Address Fax Number:
503-640-9753
Provider Enumeration Date:
09/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD25172 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023873007 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R165963 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 022740 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3276316 . This is a "CIGNA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".