Basic Information
| Provider Information | |||||||||
| NPI: | 1841301355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTTENTAG | ||||||||
| FirstName: | IRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQUARE | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135284975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14547 BRUCE B DOWNS BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139790440 | ||||||||
| FaxNumber: | 8133555054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME62562 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 371148000 | 05 | FL | MEDICAID | 200031495 | 01 | FL | RR MEDICARE | OTHER |