Provider Demographics
NPI:1992913412
Name:GUTIERREZ, MARY LOU (MD)
Entity type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
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 1:1870 W GALENA BLVD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4356
Mailing Address - Country:US
Mailing Address - Phone:630-859-6800
Mailing Address - Fax:
Practice Address - Street 1:4100 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4163
Practice Address - Country:US
Practice Address - Phone:630-851-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361078912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107891Medicaid
ILK04520Medicare ID - Type Unspecified
IL204022Medicare ID - Type Unspecified
IL036107891Medicaid