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

Table of Contents

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:
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:
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)





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