Provider Demographics
NPI:1306897038
Name:GUTIERREZ, MARIO A (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:A
Last Name:GUTIERREZ
Suffix:
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 844665
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4665
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:719 W COKE RD # MOB4
Practice Address - Street 2:STE 6
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3011
Practice Address - Country:US
Practice Address - Phone:903-342-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM91-213207T00000X
TXP0395207T00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287000801Medicaid
TX75-2616977-130OtherTRICARE
TX287000806Medicaid
TXTXB141012Medicare PIN