Provider Demographics
NPI:1063614550
Name:GUTIERREZ, PRISCILLA (MD)
Entity type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 KNOLL ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77080-6812
Mailing Address - Country:US
Mailing Address - Phone:713-984-0156
Mailing Address - Fax:713-467-9675
Practice Address - Street 1:1801 KNOLL ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77080-6812
Practice Address - Country:US
Practice Address - Phone:713-984-0156
Practice Address - Fax:713-467-9675
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB21185Medicaid
TX84M241Medicare ID - Type Unspecified