1720260060 NPI number — JOHN C GUTLEBER MD PA

Table of content: (NPI 1720260060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720260060 NPI number — JOHN C GUTLEBER MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN C GUTLEBER MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1720260060
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 NE 15TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMESTEAD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33030-4508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-247-1213
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
139 NE 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33030-4508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-247-1213
Provider Business Practice Location Address Fax Number:
305-247-5701
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUTLEBER
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
305-247-1213

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME70290 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002435404 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1012734 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 279472 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 31716 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 245462 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 250356500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43136 . This is a "NEIGHBORHOOD HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 591593951 . This is a "STAYWELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 245462 . This is a "HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7466251 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com