Provider Demographics
NPI:1225371354
Name:GUTERMAN, JACQUELINE (MD, PHD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GUTERMAN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DOROTHY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:917-679-8787
Mailing Address - Fax:
Practice Address - Street 1:78 CROMWELL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-3912
Practice Address - Country:US
Practice Address - Phone:718-987-9175
Practice Address - Fax:718-987-1322
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY287666207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program