Provider Demographics
NPI:1528092418
Name:GUTIERREZ, MIGUEL ANGEL (MD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
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 1:5767 W. CENTURY BLVD
Mailing Address - Street 2:#400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5655
Mailing Address - Country:US
Mailing Address - Phone:310-825-0631
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#450
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-0631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91383207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A913830Medicaid
CA00A913830Medicaid
CAWA91383BMedicare PIN
CAI44648Medicare UPIN