Provider Demographics
NPI:1154983971
Name:GUTIERREZ AMEZCUA, JOSE MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE MANUEL
Middle Name:
Last Name:GUTIERREZ AMEZCUA
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 1:520 2ND AVE APT 11A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8620
Mailing Address - Country:US
Mailing Address - Phone:929-218-6210
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
VT042.0018655207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-3971298Medicaid