Basic Information
| Provider Information | |||||||||
| NPI: | 1891899373 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTOWICZ | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80985 SPANISH BAY | ||||||||
| Address2: | |||||||||
| City: | LA QUINTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922538607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196774354 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 74785 HIGHWAY 111 SUITE V101 WALL ST WEST BLDG | ||||||||
| Address2: | |||||||||
| City: | INDIAN WELLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607768989 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A4090 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 2085R0202X | 20A4090 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300018971 | 01 | OH | RR MEDICARE | OTHER | 0341884 | 05 | OH | MEDICAID |