Basic Information
| Provider Information | |||||||||
| NPI: | 1124080692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | VICTORIANO | ||||||||
| MiddleName: | CAPIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5008 S. E. 42ND TRACE | ||||||||
| Address2: | |||||||||
| City: | OKEECHOBEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349741100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8637630464 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2120 SARNO RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212416800 | ||||||||
| FaxNumber: | 3212416888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME59211 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051848400 | 05 | FL | MEDICAID |