Provider Demographics
NPI:1215919469
Name:GUTTERY, EDWIN G III (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:G
Last Name:GUTTERY
Suffix:III
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 1:13740 CYPRESS TERRACE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-8827
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:9350 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7980
Practice Address - Country:US
Practice Address - Phone:239-481-5437
Practice Address - Fax:239-481-1902
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15966208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054034000Medicaid
FL36195OtherBC/BS OF FLORIDA
FL212078OtherAVMED
FL000013683BOtherHUMANA
FL27098OtherSTAYWELL
FL054034000Medicaid
FLD54420Medicare UPIN