1912428590 NPI number — DR. DENISSE LETICIA STAUFERT GUTIERREZ MD

Table of content: DR. DENISSE LETICIA STAUFERT GUTIERREZ MD (NPI 1912428590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912428590 NPI number — DR. DENISSE LETICIA STAUFERT GUTIERREZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAUFERT GUTIERREZ
Provider First Name:
DENISSE
Provider Middle Name:
LETICIA
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:
STAUFERT-GUTIERREZ
Provider Other First Name:
DENISSE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1912428590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 CLINTON CENTER DR STE 4300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39056-5610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-984-1000
Provider Business Mailing Address Fax Number:
601-815-2005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 OLD CANTON RD FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-5982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-815-2005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/04/2017

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: 2080P0006X , with the licence number:  31016 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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