Provider Demographics
NPI:1285284141
Name:GUTIERREZ, SERGIO
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E AVENUE 38
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-1504
Mailing Address - Country:US
Mailing Address - Phone:323-944-1214
Mailing Address - Fax:
Practice Address - Street 1:11303 W WASHINGTON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6003
Practice Address - Country:US
Practice Address - Phone:310-482-6600
Practice Address - Fax:310-313-0813
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA652824172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker