Provider Demographics
NPI:1366438061
Name:GUTIERREZ, ELSA D (MD)
Entity type:Individual
Prefix:DR
First Name:ELSA
Middle Name:D
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 N NEW BALLAS RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-991-8700
Mailing Address - Fax:314-991-8790
Practice Address - Street 1:522 N NEW BALLAS RD
Practice Address - Street 2:SUITE 180
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6857
Practice Address - Country:US
Practice Address - Phone:314-991-8700
Practice Address - Fax:314-991-8790
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8F97174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A12931Medicare UPIN
MOA12931Medicare UPIN
001013750Medicare PIN