Provider Demographics
NPI:1386691772
Name:GUTOW, STEFAN H (MD)
Entity type:Individual
Prefix:DR
First Name:STEFAN
Middle Name:H
Last Name:GUTOW
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 1:610 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2372
Mailing Address - Country:US
Mailing Address - Phone:505-242-3991
Mailing Address - Fax:505-243-8405
Practice Address - Street 1:610 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2372
Practice Address - Country:US
Practice Address - Phone:505-242-3991
Practice Address - Fax:505-243-8405
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0667174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01132504Medicaid