Provider Demographics
NPI:1104807627
Name:GUTIERREZ, CHARLES JOHN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOHN
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PINE ST
Mailing Address - Street 2:SUITE 1415
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-2441
Mailing Address - Country:US
Mailing Address - Phone:409-924-8600
Mailing Address - Fax:409-924-8607
Practice Address - Street 1:350 PINE ST
Practice Address - Street 2:SUITE 1415
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-2441
Practice Address - Country:US
Practice Address - Phone:409-924-8600
Practice Address - Fax:409-924-8607
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK97942086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH14814Medicare UPIN
TX324634Medicare PIN
TXH14814Medicare UPIN