1467695189 NPI number — MICHELLE RENEE GUTIERREZ-MENDOZA, M.D., INC., A PROF MED CORP

Table of content: (NPI 1467695189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467695189 NPI number — MICHELLE RENEE GUTIERREZ-MENDOZA, M.D., INC., A PROF MED CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELLE RENEE GUTIERREZ-MENDOZA, M.D., INC., A PROF MED CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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NPI Number Information

NPI Number:
1467695189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 UNIVERSITY AVE
Provider Second Line Business Mailing Address:
#1672
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92103-3395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-727-3451
Provider Business Mailing Address Fax Number:
619-260-7310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4020 FIFTH AVENUE
Provider Second Line Business Practice Location Address:
MER 14
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-686-3577
Provider Business Practice Location Address Fax Number:
619-260-7310
Provider Enumeration Date:
04/10/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUTIERREZ-MENDOZA
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
619-727-3451

Provider Taxonomy Codes

  • Taxonomy code: 282NW0100X , with the licence number:  A90028 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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