Provider Demographics
NPI:1396998977
Name:GUTIERREZ, OMAR DE JESUS (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:DE JESUS
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 1:401 11TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075-4503
Mailing Address - Country:US
Mailing Address - Phone:318-539-1701
Mailing Address - Fax:318-539-5688
Practice Address - Street 1:3601 SW 160TH AVE
Practice Address - Street 2:SUITE #250
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6308
Practice Address - Country:US
Practice Address - Phone:305-866-9951
Practice Address - Fax:877-284-8933
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250840-1207Q00000X
NY250840208600000X
LA324278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR251109001Medicaid
LA2540483Medicaid