Provider Demographics
NPI:1962694802
Name:GUTIERREZ, WILSON SY (MD)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:SY
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 1:2774 NW DAYSHA DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2980
Mailing Address - Country:US
Mailing Address - Phone:541-784-6233
Mailing Address - Fax:
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-673-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28542207R00000X, 207RH0002X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine