Provider Demographics
NPI:1215918115
Name:GUTIERREZ HERNANDEZ, MANUEL ANTONIO SR (MD)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:ANTONIO
Last Name:GUTIERREZ HERNANDEZ
Suffix:SR
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:PO BOX 112
Mailing Address - Street 2:BARBOSA AVE #209
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771
Mailing Address - Country:US
Mailing Address - Phone:787-733-0220
Mailing Address - Fax:787-716-0190
Practice Address - Street 1:JOSE C BARBOSA AVE #209
Practice Address - Street 2:
Practice Address - City:LAS PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00771
Practice Address - Country:US
Practice Address - Phone:787-733-0220
Practice Address - Fax:787-716-0190
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C84165Medicare UPIN