1932412871 NPI number — DR. JILL M BAKOTA GUTIERREZ O.D.

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 1932412871 NPI number — DR. JILL M BAKOTA GUTIERREZ O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAKOTA GUTIERREZ
Provider First Name:
JILL
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAKOTA
Provider Other First Name:
JILL
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1932412871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MARTIN ARMY COMMUNITY HOSPITAL
Provider Second Line Business Mailing Address:
6600 VAN AALST BLVD, BLDG 9250
Provider Business Mailing Address City Name:
FT MOORE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MARTIN ARMY COMMUNITY HOSPITAL
Provider Second Line Business Practice Location Address:
6600 VAN AALST BLVD, BLDG 9250
Provider Business Practice Location Address City Name:
FORT MOORE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
762-408-3498
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2010

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: 152W00000X , with the licence number:  8634 TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT002625 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 0002964 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 046010341 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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