1912191677 NPI number — DR. ELMA ROSARIO GUTIERREZ MD

Table of content: DR. ELMA ROSARIO GUTIERREZ MD (NPI 1912191677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912191677 NPI number — DR. ELMA ROSARIO GUTIERREZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
ELMA
Provider Middle Name:
ROSARIO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEREZ
Provider Other First Name:
ELMA
Provider Other Middle Name:
ROSARIO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912191677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4351 E. LOHMAN AVE.
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-522-4767
Provider Business Mailing Address Fax Number:
575-522-3607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4351 E. LOHMAN AVE.
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-522-4767
Provider Business Practice Location Address Fax Number:
575-522-3607
Provider Enumeration Date:
09/05/2007

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: 207V00000X , with the licence number:  MD2008-0075 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31284850 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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