Provider Demographics
NPI:1306939392
Name:GUTIERREZ, MANUEL LEGZSPI (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:LEGZSPI
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 1:563 TEMPLE HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553
Mailing Address - Country:US
Mailing Address - Phone:845-565-0455
Mailing Address - Fax:
Practice Address - Street 1:563 TEMPLE HILL ROAD
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553
Practice Address - Country:US
Practice Address - Phone:845-565-0455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175778208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01123115Medicaid