1760467963 NPI number — CHARLES E GUTIERREZ PH.D.

Table of content: CHARLES E GUTIERREZ PH.D. (NPI 1760467963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760467963 NPI number — CHARLES E GUTIERREZ PH.D.

Organization/Personal Information

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

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:
1760467963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8401 DATAPOINT DR STE301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-5904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-354-1186
Provider Business Mailing Address Fax Number:
210-354-1187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8401 DATAPOINT DR STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-5904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-354-1186
Provider Business Practice Location Address Fax Number:
210-354-1187
Provider Enumeration Date:
12/09/2005

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: 103TC0700X , with the licence number:  31016 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036343403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7979798 . This is a "CIGNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 87436A . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".