Provider Demographics
NPI:1124331145
Name:GUTIERREZ, STEVEN PHILLIP (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:PHILLIP
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:719-526-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3195-035152W00000X
WI3195-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty