Provider Demographics
NPI:1194777912
Name:GUTIERREZ-DIAZ, MIGUEL (DO)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:GUTIERREZ-DIAZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 BAYOU BLVD STE 2C
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2670
Mailing Address - Country:US
Mailing Address - Phone:850-501-8862
Mailing Address - Fax:850-378-0162
Practice Address - Street 1:4700 BAYOU BLVD STE 2C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2670
Practice Address - Country:US
Practice Address - Phone:850-378-0158
Practice Address - Fax:850-378-0161
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377918100Medicaid
FL57191SMedicare PIN
FLG12408Medicare UPIN