Provider Demographics
NPI:1124080692
Name:GUTIERREZ, VICTORIANO CAPIO (MD)
Entity type:Individual
Prefix:
First Name:VICTORIANO
Middle Name:CAPIO
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 1:5008 S. E. 42ND TRACE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-1100
Mailing Address - Country:US
Mailing Address - Phone:863-763-0464
Mailing Address - Fax:
Practice Address - Street 1:2120 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3084
Practice Address - Country:US
Practice Address - Phone:321-241-6800
Practice Address - Fax:321-241-6888
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051848400Medicaid
FL051848400Medicaid
FL11841Medicare ID - Type Unspecified